How to Get Mediclaim in India

Getting mediclaim in India is one of the most critical financial and health security decisions a household can make. With rising healthcare costs, unpredictable medical emergencies, and an aging population, having a reliable health insurance policy—commonly referred to as mediclaim—is no longer a luxury; it’s a necessity. Mediclaim policies provide financial protection against unexpected hospitalization expenses, covering everything from surgeries and diagnostic tests to day-care procedures and post-hospitalization care. This guide offers a comprehensive, step-by-step walkthrough on how to obtain mediclaim in India, ensuring you make informed, cost-effective, and future-proof choices.

Unlike other forms of insurance, mediclaim is deeply personal. It directly impacts your family’s access to quality healthcare, your ability to avoid debt during medical crises, and your long-term financial stability. Yet, despite its importance, many Indians remain unaware of how to navigate the process—choosing the right plan, understanding policy terms, submitting claims, and avoiding common pitfalls. This tutorial demystifies the entire process, offering actionable insights backed by industry standards and real-world experiences.

By the end of this guide, you will understand not only how to get mediclaim, but how to select the most suitable policy for your needs, maximize its benefits, and resolve issues efficiently. Whether you’re purchasing your first policy, renewing an existing one, or looking to upgrade coverage for your family, this resource is designed to empower you with clarity and confidence.

Step-by-Step Guide

Step 1: Assess Your Health Insurance Needs

Before you begin comparing policies, take time to evaluate your current and anticipated healthcare needs. Consider the following factors:

• Family size: Are you buying for yourself, your spouse, children, or elderly parents?
• Age and health status: Older individuals or those with pre-existing conditions may require higher coverage or specialized plans.
• Geographic location: Healthcare costs vary significantly between tier-1 cities and smaller towns. Urban residents often need higher sum insured due to higher hospital charges.
• Existing coverage: Do you already have employer-provided health insurance? If so, assess whether it’s sufficient or if you need a top-up plan.
• Future planning: Are you planning to start a family, undergo elective procedures, or manage chronic conditions like diabetes or hypertension?

For most individuals, a minimum sum insured of ₹5 lakh is recommended. However, in metropolitan areas or for families with senior citizens, ₹10 lakh or more is advisable. A higher sum insured reduces out-of-pocket expenses during major treatments like cancer therapy, heart surgery, or organ transplants.

Step 2: Understand the Types of Mediclaim Policies Available

India offers a variety of mediclaim plans, each tailored to specific needs. Knowing the differences helps you choose wisely:

Individual Health Insurance

This policy covers a single person. It’s ideal for young professionals or those who want personalized coverage. Premiums are calculated based on age, health, and lifestyle.

Family Floater Plan

A family floater covers multiple family members under a single policy with a shared sum insured. It’s cost-effective for nuclear families. For example, a ₹10 lakh floater can be used by any member of the family during hospitalization—no need to split the coverage.

Senior Citizen Health Insurance

Designed for individuals aged 60 and above, these plans often include coverage for age-related illnesses like arthritis, cataracts, and cardiovascular conditions. Premiums are higher due to increased risk, but many insurers offer discounts for healthy lifestyles or long-term renewals.

Group Health Insurance

Provided by employers, this policy covers employees and sometimes their dependents. While convenient, coverage may be limited. It’s wise to supplement it with an individual or floater plan.

Top-Up and Super Top-Up Plans

These are low-cost add-ons that activate when your existing coverage (like employer insurance) is exhausted. For instance, if your employer provides ₹5 lakh and you buy a ₹10 lakh top-up, your total coverage becomes ₹15 lakh once the first ₹5 lakh is used.

Critical Illness Plans

These pay a lump sum upon diagnosis of specified critical illnesses such as stroke, kidney failure, or major cancer. They complement standard mediclaim policies by covering income loss and recovery expenses.

Step 3: Compare Policies Using Key Parameters

Not all mediclaim policies are created equal. When comparing, focus on these non-negotiable parameters:

Sum Insured

Choose a sum insured that accounts for inflation and rising medical costs. A ₹5 lakh policy today may not suffice in five years. Opt for policies offering automatic restoration of sum insured or inflation protection riders.

Waiting Periods

Most policies have waiting periods for pre-existing diseases (typically 2–4 years), specific illnesses (like hernia or cataracts), and maternity benefits (usually 2–4 years). Read these carefully—some insurers offer shorter waiting periods for a higher premium.

Room Rent Capping

Many policies limit reimbursement based on room rent (e.g., 1% of sum insured per day). If your hospital charges ₹5,000 per day for a private room but your policy caps at ₹2,000, you’ll pay the difference. Choose plans with no room rent cap or higher limits.

Co-payment Clause

Some policies require you to pay a percentage of the claim amount (e.g., 10–20%). This is common in senior citizen plans. Avoid co-payment if possible, or factor it into your budget.

Network Hospitals

Network hospitals allow cashless treatment. Ensure your preferred hospitals are in the insurer’s network. A large network increases convenience, especially during emergencies.

Exclusions

Common exclusions include cosmetic surgery, dental treatments (unless due to accident), alternative medicine, and outpatient consultations. Review the fine print thoroughly.

Renewability and Age Limit

Look for lifelong renewability. Some policies stop coverage at age 65 or 70. Lifelong renewability ensures protection as you age.

Step 4: Gather Required Documents

Before applying, collect these essential documents:

• Identity proof: Aadhaar card, PAN card, or passport
• Address proof: Utility bill, bank statement, or rental agreement
• Age proof: Birth certificate, school leaving certificate, or passport
• Medical reports: For senior citizens or those with pre-existing conditions, insurers may require recent reports (e.g., ECG, blood sugar, lipid profile)
• Photographs: Recent passport-sized photos of all proposers
• Income proof (optional): Required for high-sum-insured plans or if applying for critical illness riders

If you’re adding a senior parent, ensure their medical history is documented. Disclosing accurate information prevents claim rejections later.

Step 5: Choose a Reputable Insurance Provider

India has over 25 health insurers, including public and private players. Consider the following when selecting a provider:

• Claim Settlement Ratio (CSR): This is the percentage of claims paid out of total claims received. A CSR above 90% indicates reliability. Check annual reports from the Insurance Regulatory and Development Authority of India (IRDAI).
• Customer Feedback: Look for independent reviews on platforms like Policybazaar, Coverfox, or Trustpilot. Pay attention to comments about claim processing speed and customer support responsiveness.
• Financial Stability: Choose insurers with strong solvency ratios and high credit ratings. This ensures they can honor claims even during economic downturns.
• Transparency: Avoid companies with vague policy wordings. Clear language reduces disputes during claims.

Top-performing insurers in India as of recent IRDAI reports include Star Health, HDFC ERGO, ICICI Lombard, Niva Bupa, and Max Bupa. However, always compare based on your personal needs—not just brand reputation.

Step 6: Apply Online or Through an Agent

Applying for mediclaim is now a seamless digital process:

Online Application

Visit the insurer’s official website or a trusted insurance aggregator. Fill in personal details, health declarations, and coverage preferences. Most platforms offer instant quotes and allow you to compare multiple policies side-by-side. Upload documents electronically and pay via UPI, net banking, or card. You’ll receive the policy document via email within 24–48 hours.

Through an Agent or Broker

If you prefer personal guidance, consult a licensed insurance agent or broker. Brokers represent multiple insurers and can help you find the best fit. Ensure they are registered with IRDAI. Avoid agents who push high-commission plans without explaining terms.

Regardless of the channel, never skip reading the policy document before paying. Look for clauses on pre-existing disease coverage, sub-limits, and claim procedures.

Step 7: Complete the Waiting Period

Once your policy is active, you must wait for specified periods before certain benefits kick in:

• Pre-existing diseases: 2–4 years (varies by insurer)
• Maternity: 2–4 years
• Specific illnesses: 90 days to 1 year (e.g., cataract, hernia)

During this time, avoid hospitalization for covered conditions unless it’s an emergency. If you must seek treatment, pay out-of-pocket and retain all bills—you may be eligible for reimbursement after the waiting period ends, depending on policy terms.

Step 8: Understand the Claim Process

There are two types of claims: cashless and reimbursement.

Cashless Claim

Available only at network hospitals. At admission, inform the hospital’s insurance desk that you have a mediclaim policy. They will verify your details with the insurer’s TPA (Third Party Administrator). Once approved, the hospital directly settles the bill with the insurer. You only pay for non-covered items like medicines, diagnostics, or room upgrades beyond the policy limit.

Reimbursement Claim

Used when you’re treated at a non-network hospital or if cashless approval fails. Follow these steps:

1. Pay all hospital bills upfront.
2. Collect original documents: discharge summary, itemized bills, prescriptions, diagnostic reports, and doctor’s notes.
3. Fill out the claim form (available on the insurer’s website).
4. Submit documents within 15–30 days of discharge.
5. Wait for processing (typically 7–21 days).
6. Receive payment via NEFT or check.

Always keep digital and physical copies of all documents. Delays often occur due to missing paperwork.

Step 9: Renew Your Policy on Time

Mediclaim policies are annual. Renewal is not automatic. Missing the deadline may result in loss of benefits, including coverage for pre-existing conditions and accumulated no-claim bonuses.

Most insurers send renewal reminders via email or SMS. Set calendar alerts. Renew early to avoid lapses. Some insurers offer discounts for continuous renewal without claims—up to 50% over time.

If your health status has changed (e.g., new diagnosis), inform your insurer during renewal. Non-disclosure can lead to claim denial.

Step 10: Optimize Your Coverage Over Time

Your healthcare needs evolve. Regularly review your policy:

• Upgrade sum insured every 2–3 years to match inflation.
• Add riders like daily hospital cash, ambulance cover, or wellness benefits.
• Consider switching insurers if your current provider has low claim settlement ratios or poor network coverage.
• Use health check-ups offered by insurers to monitor wellness and potentially reduce premiums.

Some insurers reward healthy behavior with discounts on premiums for regular exercise, non-smoking status, or maintaining healthy BMI. Take advantage of these incentives.

Best Practices

Disclose All Medical History Accurately

Hiding pre-existing conditions or past hospitalizations is the leading cause of claim rejection. Even if a condition seems minor—like high blood pressure or a past appendectomy—disclose it. Insurers have access to medical databases and may find discrepancies later. Full disclosure protects your claim rights and builds trust with the insurer.

Opt for No-Claim Bonus (NCB)

Most policies offer a no-claim bonus—a percentage increase in sum insured for each claim-free year. For example, a ₹5 lakh policy may increase to ₹5.5 lakh after one year without a claim. Some insurers offer up to 100% bonus over time. Never cancel your policy to switch insurers if you have accumulated NCB; most allow transfer of the bonus.

Understand Sub-Limits and Caps

Many policies impose sub-limits on specific treatments—for example, only ₹1 lakh for knee replacement or ₹50,000 for cataract surgery. These can significantly reduce your payout. Choose plans with minimal or no sub-limits, especially if you’re in a high-risk group.

Use Health Check-Ups and Wellness Programs

Insurers often provide free annual health check-ups or discounts on gym memberships, nutrition counseling, or teleconsultations. Participating not only improves your health but may also reduce future premiums. Some policies even offer rewards points redeemable for discounts on future premiums.

Keep Digital Records

Store all policy documents, claim receipts, and correspondence in a secure cloud folder. Use apps like Google Drive or Dropbox with password protection. In case of emergencies, quick access to documents speeds up claim processing.

Don’t Rely Solely on Employer Coverage

Employer-provided insurance is often limited in sum insured and may lapse if you change jobs. Always have an individual or family floater plan as your primary coverage. Think of employer insurance as a secondary layer.

Review Policy Annually

Healthcare costs rise by 10–15% annually. Review your policy each year to ensure your sum insured still meets your needs. If you’ve had a child, bought a home, or moved to a city with higher medical costs, adjust your coverage accordingly.

Teach Family Members About the Policy

Ensure your spouse, children, or elderly parents know where the policy documents are stored, how to access the insurer’s portal, and what to do in an emergency. This prevents delays during crises.

Tools and Resources

IRDAI Website

The Insurance Regulatory and Development Authority of India (https://www.irdai.gov.in) is the official regulator. Use it to:

• Verify insurer licenses
• Check claim settlement ratios by company
• Access standardized policy wordings
• File complaints if needed

Insurance Aggregators

Platforms like Policybazaar, Coverfox, and BankBazaar allow you to compare policies from multiple insurers side-by-side. They offer:

• Instant premium quotes
• Customized plan recommendations
• Online application and document upload
• Customer reviews and ratings

Use these tools to shortlist 3–5 policies before making a final decision.

Health Insurance Calculators

Most aggregator sites and insurer portals offer premium calculators. Input your age, location, desired sum insured, and add-ons to estimate costs. Use them to budget effectively.

Mobile Apps

Insurers like Niva Bupa, HDFC ERGO, and Star Health offer dedicated apps that let you:

• View policy details
• Initiate cashless requests
• Track claim status
• Access digital ID cards
• Book health check-ups

Download your insurer’s app immediately after buying a policy.

Medical Cost Estimators

Use platforms like Practo or Lybrate to estimate average costs for common procedures in your city. For example:

• Coronary angioplasty: ₹2–5 lakh
• Knee replacement: ₹3–6 lakh
• Cataract surgery: ₹30,000–1.5 lakh
• Appendectomy: ₹80,000–2 lakh

This helps you determine the right sum insured.

Government Health Schemes

While not mediclaim, government schemes like Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) provide ₹5 lakh coverage per family per year for secondary and tertiary care. If you’re eligible (based on socio-economic criteria), you can use this alongside your private policy for enhanced protection.

Real Examples

Example 1: Ravi, 32, IT Professional in Bangalore

Ravi earns ₹12 lakh annually and works for a mid-sized tech firm that offers ₹3 lakh employer coverage. He has no chronic conditions but wants to protect against emergencies. He researches policies and chooses a ₹10 lakh family floater from HDFC ERGO, covering himself, his wife, and their 5-year-old daughter. He pays ₹8,500 annually. Two years later, his daughter needs tonsillectomy. The hospital is in-network, and the claim is processed cashlessly within 24 hours. He retains his no-claim bonus and upgrades his sum insured to ₹15 lakh the following year.

Example 2: Meena, 68, Retired Teacher in Jaipur

Meena has diabetes and hypertension. Her son, a software engineer in Delhi, buys her a senior citizen plan from Star Health with ₹7 lakh coverage, no co-payment, and a 1-year waiting period for pre-existing conditions. The policy includes free annual health check-ups. After a year, she is hospitalized for a heart procedure. The claim is approved with full coverage. She now receives wellness incentives and reduced premiums for maintaining stable vitals.

Example 3: The Sharma Family, Delhi

The Sharmas have a ₹5 lakh floater policy for five years. They’ve never made a claim and have accumulated a 50% NCB, increasing their sum insured to ₹7.5 lakh. When the father suffers a stroke, the hospital bills total ₹9 lakh. The policy pays ₹7.5 lakh, and they use a ₹5 lakh top-up plan to cover the remaining ₹1.5 lakh. Their total coverage of ₹12.5 lakh prevents financial strain.

Example 4: Vikram, 45, Small Business Owner in Pune

Vikram runs a small retail business and has no employer coverage. He buys an individual plan with ₹10 lakh coverage and adds a critical illness rider for ₹5 lakh. A year later, he is diagnosed with stage 2 colon cancer. The critical illness rider pays him ₹5 lakh as a lump sum, which he uses for travel, nutrition, and lost income. His mediclaim covers the ₹8 lakh treatment cost. He survives with minimal debt thanks to layered coverage.

FAQs

Can I get mediclaim if I have a pre-existing disease?

Yes. Most insurers accept applicants with pre-existing conditions but impose a waiting period—usually 2 to 4 years. Disclose the condition honestly during application to avoid claim denial.

Is maternity covered under mediclaim?

Yes, but only under specific plans and after a waiting period of 2 to 4 years. Some policies cover only delivery costs; others include pre- and post-natal care. Check the policy wording.

Can I buy mediclaim for my parents who are over 70?

Yes. Many insurers offer senior citizen plans up to age 80 or even lifelong renewability. Premiums are higher, but coverage is available. Compare policies carefully for pre-existing disease coverage.

What happens if I miss the renewal date?

If you miss the renewal date, you typically have a grace period of 15–30 days. After that, the policy lapses. You may lose accumulated no-claim bonus and have to re-serve waiting periods for pre-existing conditions.

Are diagnostic tests like MRI or CT scans covered?

Yes, if they are part of hospitalization. Outpatient diagnostic tests are usually excluded unless covered under a wellness rider.

Can I have more than one mediclaim policy?

Yes. You can hold multiple policies. In case of a claim, you can file with one insurer first and then use the second for remaining expenses. This is common with top-up plans.

Does mediclaim cover dental treatment?

Only if the treatment results from an accident. Routine dental care, orthodontics, or cosmetic procedures are excluded.

How long does a claim take to settle?

Cashless claims are approved within hours. Reimbursement claims take 7 to 21 days if documents are complete. Delays occur due to missing paperwork or disputes over coverage.

Is there a tax benefit for buying mediclaim?

Yes. Under Section 80D of the Income Tax Act, you can claim deductions of up to ₹25,000 for self, spouse, and children. An additional ₹25,000 is allowed for parents. For senior citizen parents, the limit is ₹50,000.

Can I switch insurers without losing benefits?

Yes. IRDAI allows portability. You can switch insurers at renewal time and carry forward benefits like waiting periods and no-claim bonus. Ensure you apply for portability through the new insurer’s portal.

Conclusion

Getting mediclaim in India is not merely about purchasing a policy—it’s about securing your family’s health, financial stability, and peace of mind. The process, while initially complex, becomes straightforward when approached systematically: assess your needs, compare policies with precision, disclose health details honestly, and renew consistently. The real value of mediclaim isn’t seen in premium payments—it’s revealed during emergencies, when a policy transforms from a document into a lifeline.

With healthcare costs rising and medical emergencies becoming more common, delaying coverage is a gamble no household can afford. Whether you’re young and healthy or caring for aging parents, the time to act is now. Use the tools, follow the best practices, and learn from real examples to make a decision that lasts a lifetime.

Remember: the best mediclaim policy isn’t the cheapest—it’s the one that aligns with your health profile, financial capacity, and future needs. Invest wisely. Protect thoroughly. And never underestimate the power of being prepared.