How to Get Mediclaim in India

Getting mediclaim in India is one of the most important financial and health-related decisions a household can make. With rising healthcare costs, unpredictable medical emergencies, and an aging population, having adequate health insurance coverage is no longer a luxury—it’s a necessity. Mediclaim, commonly referred to as health insurance in India, provides financial protection against medical expenses incurred due to hospitalization, surgeries, diagnostic tests, and sometimes even outpatient treatments. This comprehensive guide walks you through every step required to obtain mediclaim coverage in India, from understanding the basics to selecting the right plan, submitting applications, and maximizing benefits. Whether you’re a first-time buyer, a parent planning for your family, or someone looking to upgrade existing coverage, this tutorial equips you with actionable insights backed by industry standards and real-world examples.

Step-by-Step Guide

Understand What Mediclaim Covers

Before applying for any mediclaim policy, it’s critical to understand the scope of coverage. Mediclaim policies in India typically cover hospitalization expenses, including room charges, doctor fees, surgical costs, anesthesia, medicines, diagnostic tests, and pre- and post-hospitalization care. Most policies offer coverage for a period of 30 days before and 60 to 90 days after hospitalization. Some advanced plans also include day-care procedures such as chemotherapy, dialysis, and cataract surgery. Certain policies extend coverage to maternity benefits, dental treatments, and alternative therapies like Ayurveda or homeopathy, but these are often optional riders.

It’s equally important to know what is excluded. Common exclusions include pre-existing conditions during the waiting period (usually 2 to 4 years), cosmetic surgeries, infertility treatments, and injuries resulting from self-harm or substance abuse. Always review the policy document’s fine print. Understanding coverage limits, sub-limits on room rent, and co-payment clauses will help you avoid unpleasant surprises during a claim.

Assess Your Healthcare Needs

Not all mediclaim policies are the same. Your choice must align with your personal and family health profile. Consider the following factors:

• Age: Older individuals typically require higher coverage due to increased risk of chronic illnesses.
• Family Structure: If you’re planning to cover your spouse, children, or dependent parents, a family floater plan may be more cost-effective than individual policies.
• Medical History: If you or any family member has a history of diabetes, hypertension, or heart conditions, look for insurers with shorter waiting periods for pre-existing diseases.
• Location: Urban areas have higher medical costs. If you live in cities like Mumbai, Delhi, or Bangalore, consider a minimum sum insured of ₹10 lakh or more.
• Lifestyle: Smokers, alcohol users, or those with sedentary lifestyles may face higher premiums or exclusions.

For young, healthy individuals, a basic plan with ₹5 lakh coverage may suffice. However, for families with elderly members or those living in metro cities, a sum insured of ₹10–20 lakh is recommended to account for inflation and advanced treatments.

Compare Policies from Multiple Insurers

India has over 25 insurance companies offering mediclaim, including public sector giants like National Insurance and New India Assurance, and private players such as HDFC Ergo, ICICI Lombard, Star Health, and Max Bupa. Each offers distinct features:

• Network Hospitals: Check the number and quality of hospitals in your city that are part of the insurer’s cashless network. A larger network means easier access to treatment without upfront payments.
• Claim Settlement Ratio (CSR): This is the percentage of claims approved out of total claims received. A CSR above 90% indicates reliability. According to IRDAI data, top performers consistently maintain CSR above 95%.
• Waiting Periods: Standard waiting periods are 30 days for new illnesses, 2–4 years for pre-existing conditions, and 9–24 months for maternity. Compare these across policies.
• Renewability: Ensure the policy is renewable for life. Some insurers cap renewability at age 65 or 70.
• No Claim Bonus (NCB): Most policies offer a discount on premium (up to 50%) for every claim-free year. This can significantly reduce long-term costs.

Use online comparison platforms to evaluate policies side-by-side. Input your age, location, desired coverage, and any existing conditions to get real-time quotes. Don’t just pick the cheapest plan—evaluate value, not just price.

Choose Between Individual and Family Floater Plans

There are two primary types of mediclaim plans in India:

• Individual Health Insurance: Each family member has a separate policy with their own sum insured. Ideal for those who want personalized coverage or have members with different health needs.
• Family Floater Plan: A single policy covers the entire family under one sum insured. This is cost-efficient and ideal for nuclear families with similar health profiles.

For example, a family floater plan with ₹10 lakh coverage for a family of four costs significantly less than four individual ₹10 lakh policies. However, if one member exhausts the entire sum insured through a major surgery, others lose coverage until renewal. In contrast, individual plans ensure each person retains full coverage regardless of others’ claims.

Consider hybrid options: a family floater for immediate members and separate policies for elderly parents, who often require higher coverage due to age-related risks.

Gather Required Documents

Applying for mediclaim requires specific documentation to verify identity, age, address, and health status. Common documents include:

• Government-issued photo ID (Aadhaar card, PAN card, passport, or driver’s license)
• Proof of address (utility bill, bank statement, or Aadhaar)
• Age proof (birth certificate, school leaving certificate, or passport)
• Medical reports (if applying after age 45 or if declaring pre-existing conditions)
• Recent passport-sized photographs

Some insurers require a medical check-up for applicants above 45–50 years of age, especially if the sum insured exceeds ₹10 lakh. These check-ups are usually conducted at empaneled diagnostic centers and may include blood tests, ECG, ultrasound, and urine analysis. The cost of the medical test is often borne by the insurer.

Ensure all documents are clear, legible, and up-to-date. Incomplete or mismatched documents can delay approval or result in policy rejection.

Fill Out the Application Form Accurately

Applications can be submitted online via the insurer’s website or through authorized agents. Online applications are faster and often come with discounts. Whether digital or paper-based, accuracy is paramount.

Key sections to complete carefully:

• Personal Details: Full name, date of birth, gender, contact information, and occupation.
• Health Declarations: Disclose all past illnesses, hospitalizations, surgeries, and ongoing treatments. Hiding information can lead to claim rejection even after years.
• Sum Insured and Policy Term: Select the coverage amount and duration (typically 1 year, renewable).
• Additional Riders: Choose optional benefits like critical illness cover, daily hospital cash, or accidental death benefit. These add value but increase premium.

Always read the terms before signing. Many applicants skip this step and later face disputes. If unsure, consult a licensed insurance advisor or use the insurer’s live chat support for clarification.

Pay the Premium and Receive Policy Documents

After submitting the application, you’ll receive a premium quote. Payment can be made via net banking, UPI, credit/debit card, or NEFT. Once payment is confirmed, the insurer processes your application.

For policies requiring medical tests, approval is granted only after the reports are reviewed and accepted. This may take 3–7 working days. Once approved, you’ll receive the policy document via email and sometimes by post. The document includes:

• Policy number and start/end dates
• Sum insured and coverage details
• Exclusions and waiting periods
• Network hospital list
• Claim procedure instructions
• Customer portal login credentials

Save a digital and printed copy. Store them in a secure, accessible location. Many insurers now offer digital wallets or mobile apps where you can store your policy, access cashless hospitalization, and track claims.

Activate Cashless Hospitalization

One of the biggest advantages of mediclaim is cashless treatment. To use this feature:

1. Visit a hospital within the insurer’s network (available on their website or app).
2. Inform the hospital’s insurance desk that you intend to use mediclaim.
3. Present your policy document and photo ID.
4. The hospital will contact the insurer or Third Party Administrator (TPA) for pre-authorization.
5. Once approved, you can proceed with treatment without paying anything upfront.

Pre-authorization is mandatory for planned hospitalizations. In emergencies, notify the insurer within 24 hours and submit documents later. Keep a copy of all discharge summaries and bills, even if treatment was cashless.

File Claims for Reimbursement

If you’re treated at a non-network hospital or require outpatient care not covered under cashless, you’ll need to file a reimbursement claim. Follow these steps:

1. Collect all original documents: discharge summary, itemized hospital bills, prescriptions, diagnostic reports, and payment receipts.
2. Fill out the claim form available on the insurer’s website or from their office.
3. Attach supporting documents and submit via email, post, or the insurer’s portal.
4. Track your claim status online. Most insurers update status within 48 hours.
5. Once approved, the reimbursement is credited to your bank account within 7–15 days.

Ensure all documents are signed, stamped, and clearly labeled. Incomplete submissions are the leading cause of claim delays.

Best Practices

Start Early

Health insurance is cheaper and more accessible when you’re young and healthy. Premiums increase with age, and medical underwriting becomes stricter. Starting in your 20s or 30s ensures lower premiums, longer coverage, and better terms. Many insurers offer lifetime renewability only if you’ve maintained continuous coverage since a young age.

Don’t Skip the Medical Check-Up

Even if it’s optional, undergoing a medical check-up when applying builds trust with the insurer. It provides a baseline of your health, reducing the chance of future claim disputes. If you have a minor condition like borderline cholesterol, disclosing it upfront allows the insurer to cover it after the waiting period, rather than excluding it later.

Renew Without Gaps

Letting your policy lapse—even for a few days—can result in loss of accumulated benefits like No Claim Bonus and continuity of pre-existing condition coverage. Always renew before the expiry date. Most insurers send reminders via SMS or email, but don’t rely solely on them.

Review Annually

Your health needs change. A policy that was sufficient at age 30 may be inadequate at 45. Annually review your coverage against inflation, new family members, or emerging health conditions. Consider increasing your sum insured or adding riders as needed.

Use Digital Tools

Modern insurers offer apps and online portals for policy management, claim filing, and hospital location searches. Enable notifications, upload documents digitally, and use chat support for quick queries. Digital-first users often experience faster service and fewer errors.

Understand the Fine Print

Many claim rejections occur due to misunderstandings about policy terms. For instance, some policies limit room rent to a percentage of the sum insured (e.g., 1%). If your room costs ₹5,000/day and your sum insured is ₹5 lakh, the insurer may cap room rent at ₹500/day, reducing your overall claim. Always clarify such clauses before purchasing.

Bundle with Other Insurance

Some insurers offer discounts if you bundle mediclaim with other policies like term life or motor insurance. While this shouldn’t be your primary reason to choose a provider, it can reduce costs. Always compare standalone mediclaim quotes first.

Keep Records for Life

Store all policy documents, claim receipts, and medical reports in a dedicated folder—physical or digital. These records are vital for future renewals, portability, or if you switch insurers. Even after a claim is settled, retain documents for at least 5 years.

Tools and Resources

Insurance Regulatory and Development Authority of India (IRDAI)

IRDAI is the official regulator of insurance in India. Their website (irdai.gov.in) provides a list of licensed insurers, consumer guidelines, claim settlement ratios, and complaint mechanisms. Use this to verify whether an insurer is legitimate and to compare performance metrics across companies.

Online Comparison Platforms

Platforms like Policybazaar, Coverfox, BankBazaar, and CompareRoot allow you to compare hundreds of mediclaim plans based on premium, coverage, exclusions, and customer ratings. These sites often provide personalized recommendations and exclusive discounts. Always cross-check the final quote with the insurer’s official website before purchasing.

Insurer Mobile Apps

Most major insurers have dedicated apps for policyholders. Examples include HDFC Ergo’s “HDFC ERGO Health” app, ICICI Lombard’s “ICICI Lombard Health” app, and Star Health’s “Star Health Mobile App.” These apps allow you to:

• View policy details
• Download e-policy documents
• Locate network hospitals
• Initiate cashless requests
• Track claim status
• Upload documents

Download the app of your chosen insurer immediately after purchasing your policy.

Health Insurance Portability Portal

IRDAI allows policyholders to switch insurers without losing benefits like waiting period credits for pre-existing conditions. Use the official portability portal (irdai.gov.in/health-portability) to transfer your policy from one insurer to another. This is useful if you’re dissatisfied with service or find a better plan. Portability must be initiated 45 days before your policy expiry.

Diagnostic Center Networks

Many insurers partner with diagnostic chains like Thyrocare, SRL Diagnostics, and Dr. Lal PathLabs for affordable health check-ups. If your policy requires a medical test, ask your insurer which centers are empaneled. Tests at these locations are often free or subsidized.

Government Health Schemes

While not a substitute for private mediclaim, government schemes like Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) provide ₹5 lakh annual coverage to eligible low-income families. Check eligibility at pmjay.gov.in. If you qualify, you may use this as a base layer and supplement it with a private policy for higher coverage or better hospital access.

Real Examples

Example 1: Young Professional in Bangalore

Rahul, 28, works in IT in Bangalore. He earns ₹12 lakh annually and lives alone. He purchased a ₹10 lakh individual mediclaim plan from ICICI Lombard for ₹5,200 per year. The policy includes cashless treatment at 1,200+ hospitals, 30-day pre-hospitalization coverage, and a 50% No Claim Bonus. He had no medical history. After one year without claims, his premium dropped to ₹3,900. When he needed appendicitis surgery, he was treated cashlessly at a network hospital, and the entire ₹1.8 lakh bill was settled without any out-of-pocket expense.

Example 2: Family in Pune with Elderly Parents

The Sharma family—parents aged 62 and 65, and two children aged 25 and 22—opted for a family floater of ₹15 lakh with Star Health. They added a critical illness rider for ₹5 lakh and a daily cash benefit of ₹2,000. The annual premium was ₹18,500. When the father was diagnosed with a heart blockage, the hospitalization cost ₹4.2 lakh. The insurer approved cashless treatment, paid the full amount, and the daily cash benefit helped cover food and transport expenses. The children’s coverage remained intact despite the high claim.

Example 3: Switching Insurers with Portability

Sunita, 40, had a ₹5 lakh policy with a public sector insurer for 5 years. She had a pre-existing diabetes diagnosis, which was covered after the 4-year waiting period. She found a private insurer offering ₹10 lakh coverage with better network hospitals and faster claim processing. She initiated portability 45 days before renewal. Her new insurer accepted her existing waiting period for diabetes and offered the higher sum insured without a new medical test. She saved ₹2,000 annually and gained access to 800 more hospitals.

Example 4: Reimbursement Claim After Emergency

Amit, 35, was involved in a road accident in a small town without network hospitals. He was admitted to a local private hospital and paid ₹95,000 out of pocket. He submitted all documents—emergency report, bills, prescriptions, and discharge summary—to his insurer, HDFC Ergo, within 15 days. The claim was processed in 11 days, and ₹92,000 was reimbursed. He retained the original documents and kept a copy of the claim settlement letter for future reference.

FAQs

Can I get mediclaim if I have diabetes or hypertension?

Yes. Most insurers offer coverage to individuals with pre-existing conditions like diabetes and hypertension, but with a waiting period of 2 to 4 years. Disclose your condition during application. After the waiting period, related treatments are covered. Some insurers specialize in senior citizen or diabetic-friendly plans with shorter waiting periods.

Is maternity covered under mediclaim?

Maternity coverage is typically an add-on rider and not included in standard plans. It usually has a waiting period of 9 to 24 months and covers delivery expenses, pre- and post-natal care, and newborn care for up to 90 days. Check if your plan includes it and what the sub-limits are.

Can I buy mediclaim for my parents who are over 60?

Yes. Many insurers offer senior citizen health plans for individuals up to age 80. Premiums are higher due to increased risk, but coverage is essential. Look for plans with no upper age limit for renewal and comprehensive coverage for age-related ailments like joint replacements, cataracts, and kidney failure.

What happens if I miss the renewal date?

If you miss the renewal date, most insurers provide a grace period of 15–30 days. During this time, your policy remains active, and claims are still honored. After the grace period, the policy lapses. You’ll lose accumulated No Claim Bonus and may have to undergo a new medical check-up. Pre-existing conditions will be subject to fresh waiting periods.

Can I have more than one mediclaim policy?

Yes. You can hold multiple policies from different insurers. In case of a claim, you can split the expenses between policies. However, total reimbursement cannot exceed actual expenses incurred. This is useful for increasing coverage beyond ₹10 lakh or for specialized needs like critical illness riders.

Are dental and eye treatments covered?

Standard mediclaim policies cover dental and eye treatments only if they require hospitalization. For example, wisdom tooth extraction under anesthesia or cataract surgery is covered. Routine dental cleanings, glasses, or contact lenses are not. Some insurers offer add-ons for dental and optical care—check for these riders.

Does mediclaim cover Ayurveda or homeopathy?

Some policies include coverage for alternative medicine, but only if treatment is received in a recognized hospital or center. Outpatient treatments at homeopathic clinics are usually excluded. Always confirm this with your insurer before purchasing.

How long does it take to get a mediclaim policy approved?

If no medical test is required, approval can take 2–3 working days. If a medical check-up is needed, it may take 5–10 days. Online applications are faster. Delays occur if documents are incomplete or if the insurer requests additional information.

Can I port my mediclaim policy to another insurer?

Yes. IRDAI allows portability. You can switch insurers without losing benefits like waiting periods for pre-existing conditions, provided you apply 45 days before your current policy expires. Use the official IRDAI portability portal to initiate the process.

Is a mediclaim policy valid across India?

Yes. Most policies offer pan-India coverage. You can access cashless treatment at any network hospital in the country. However, some insurers have limited networks in rural areas. Always check the hospital list before traveling.

Conclusion

Obtaining mediclaim in India is a straightforward process when approached with clarity, preparation, and diligence. From understanding your healthcare needs to selecting the right policy, gathering documents, and filing claims, each step plays a vital role in ensuring uninterrupted protection. The key is not just to buy a policy, but to choose one that evolves with your life—adjusting for age, family size, medical history, and inflation.

Mediclaim is more than a financial product—it’s peace of mind. In a country where out-of-pocket healthcare spending remains high, having the right coverage shields your savings, reduces stress during emergencies, and ensures timely access to quality care. Use the tools, follow the best practices, and learn from real-life examples to make an informed decision.

Start today. Don’t wait for a medical emergency to realize the value of mediclaim. Whether you’re 25 or 65, the best time to secure your health coverage is now. Review your options, compare policies, and take the first step toward a healthier, more secure future.