Mediclaim or Health Policy – What’s Best for Family Coverage in 2024?

Mediclaim or health policy? If you are confused whether one is better than another, here's a quick guide to help you decide.
Happy family seeking healthcare policy
Understand the difference between mediclaim and health insurance policy. Image courtesy: Adobe Stock
HT Brand Studio Published: 15 Dec 2023, 04:04 pm IST
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Securing robust health coverage for your family is crucial today, with medical inflation rates continuously rising. However, the variety of health insurance products in India often confuses buyers.

The two most common options are mediclaim policies and health insurance plans. While they have some similarities, there are also significant differences one must consider before purchasing family health coverage in 2024.

This comprehensive guide examines mediclaim and health insurance in detail. It compares various parameters to help you make the right choice for adequate family health protection.

Understanding Mediclaim Policies

A mediclaim policy for family offers basic inpatient hospitalisation coverage. It reimburses the associated medical bills if hospitalised due to illness, disease or injury. Key highlights of mediclaim policies:

  • Hospitalisation Cover: Mediclaim policies cover only expenses incurred during hospitalisation, requiring 24+ hours of admission.
  • Limited Benefits: The coverage is quite bare-bones, with many exclusions. Outpatient services are not covered.
  • Affordable Premiums: Premiums are lower, but so are the benefits. This makes it an economical way to hedge against hospital bills.
  • Cashless Facility: Available only at network hospitals on producing the mediclaim card. Reimbursement mechanism for non-network hospitals.
  • Tax Benefits: Premiums privilege for tax deduction under Section 80D, boosting savings.
  • Policy Tenure: Generally valid for 1 year, after which one has to renew the mediclaim policy.

Types of Mediclaim

Catering to varied segments, there are different mediclaim options:

  • Individual: Covers hospitalisation of the policyholder only
  • Family Floater: Insures 2+ family members under one policy
  • Senior Citizen: Tailored coverage for elderly people
  • Group: Provided by employers, covers company employees
  • Critical Illness: Additional payout on hospitalisation due to specified critical illnesses
  • Top-Up: Provides supplementary coverage over and above an existing mediclaim policy

What Does Mediclaim Cover?

Hospitalisation expenses covered under mediclaim include:

  • Room rent, boarding charges
  • Intensive Care Unit (ICU) charges
  • Fees of surgeons, specialists, anaesthetists
  • Medicines, drugs, diagnostic tests
  • Operation theatre charges
  • Recovery benefits like physiotherapy
  • Taxation Benefits
  • Day Care Treatments
  • Domiciliary Hospitalisation

However, there are extensive exclusions like:

  • Corrective Cosmetic Surgery
  • Permanent Exclusions
  • Self-Induced Injuries
  • Injuries Inflicted Due to Alcohol Consumption
  • Prior Diseases
  • Sexually Transmitted Diseases
  • Infertility Treatment
  • Inherent Diseases

Mediclaim Premium Calculation

Insurers determine mediclaim premiums basis parameters like:

  • Age – Higher age leads to increased premiums
  • Location – Varies based on city and associated medical inflation
  • Pre-existing conditions – Additional loading for existing illnesses
  • Lifestyle habits like smoking – Higher premiums
  • Sum insured – The higher the coverage, the higher the premium
  • Policy tenure – 1 year is the norm for mediclaim
  • Number of members covered – Family floaters cost more

Insurers calculate premiums strictly as per IRDAI’s regulations. Entry age, medical history and sum insured primarily decide the mediclaim policy rate.

Understanding Health Insurance Plans

Health insurance provides extensive coverage beyond basic inpatient hospitalisation. Some key aspects:

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  • Inpatient + Outpatient Cover: Health plans cover hospitalisation (IPD) and outpatient (OPD) treatment.
  • Enhanced Network: Over 7000+ networked hospitals provide cashless claim facilities across India.
  • Additional Covers: Range of complimentary benefits and optional add-on covers.
  • Tenure: Longer 2-3 year policy tenure ensures health protection for a longer duration.
  • Premium: Comprehensive coverage and higher benefits translate to higher premiums.
  • Tax Savings: Significant tax savings opportunity under Section 80D, up to ₹25,000 for self and family.

There are also specialised health insurance plans like:
1. Family Floater Health Insurance
2. Senior Citizen Health Insurance
3. Critical Illness Health Insurance
4. Group Health Insurance
5. Top-up Health Insurance

What Does Health Insurance Cover?

Health insurance delivers all-round protection encompassing:

  • ICU, OT and room rent
  • Surgeon, specialists, anaesthetists fees
  • Medicines, diagnostic tests
  • Doctor consultations
  • Medicines
  • Diagnostic tests
  • Dental treatments (medically necessary)
  • Mental health consultations

What is not covered?

  • Cosmetic Procedures (unless required due to an accident)
  • New Technology in Products or Services
  • Off-Label Prescriptions
  • Fertility Treatments

Health Insurance Premium Calculation

With extensive coverage, health insurance premiums are higher than mediclaim. The Health Insurance Premium Calculator considers:

  • Age – Higher age means a higher premium
  • Pre-existing diseases – loading as per conditions
  • Location – Varies based on city and medical inflation
  • Lifestyle habits like smoking and alcohol – loadings apply
  • Sum insured – The higher the coverage, the higher the premium
  • Policy tenure – 2 and 3-year options available
  • Add-ons selected – More covers mean higher premium
  • Family size – Floater plans for bigger families cost more

Which is Better in 2024 – Mediclaim or Health Insurance?

While mediclaim serves as basic hospitalisation cover, health policy plans are a more evolved option providing end-to-end protection.

Reasons Why Health Insurance Scores Over Mediclaim

  • Outpatient Department Cover: Health plans cover OPD costs like doctor fees, medicines, diagnostics, etc. Mediclaim restricts itself to hospitalisation only.
  • Numerous Add-on Covers: From dental treatment to spectacles to mental health consultations, health insurance provides a range of additional covers.
  • Large Hospital Network: Hundreds of hospitals provide cashless facilities against a handful in mediclaim, ensuring access wherever you are.
  • Longer Tenure: The 2-3 years policy term ensures you get longer coverage than annual mediclaim.
  • Greater Flexibility: Available options to tweak health insurance as per budget and need to make it a superior alternative.
  • Higher Tax Savings: With higher premiums, the tax deduction opportunity under Section 80D increases substantially (subject to the tax regime opted for.).

However, mediclaim serves as an affordable alternative covering hospital bills for those with limited budgets or seeking bare-bones coverage. So, based on specific priorities, one can opt between a mediclaim policy and a more benefit-rich health insurance plan when securing health for your family.

Summing Up

Safeguarding your family’s health is non-negotiable today, with rising medical inflation making hospitalisations expensive. One has twin options to hedge against medical uncertainties – mediclaim policies and more advanced health insurance plans. While mediclaim offers basic hospital expense coverage, health insurance provides extensive protection. Based on individual priorities, budget and health objectives, one can make the optimal choice when buying coverage for a family in 2024.

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