If you are looking to buy a health insurance policy in India (also referred to commonly as Mediclaim policy), you must understand the coverage you can get from the policy so that you can compare the different plans. Typical benefits from health insurance or mediclaim policies in India fall under the following categories: 

• Hospitalization Cover or in-patient expenses: Protects the insured person or family (in case of family floater plan) for in-patient hospitalization expenses as a result of suffering illness or bodily injury during the period of insurance, which on the advice of a medical practitioner requires hospitalization. These include room and boarding charges as per policy conditions.
• Day care expenses or out-patient expenses: Day Care expenses incurred on advanced technological surgeries and procedures like Dialysis, Radiotherapy, and Chemotherapy, requiring less than 24 hours of hospitalisation.
• Doctor’s fees, Specialists’ fees, Anaesthetist fees, Surgeon’s fees
• Nursing Expenses
• Cost of Medicines and Drugs: This may include Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and Organs and similar expenses.
• Nursing Expenses
• Maternity Expenses: Costs incurred during child-birth are covered under this category. Different limits for coverage are typically applicable for Normal Delivery and Caesarean Delivery. Note that most policies cover maternity expenses only after a waiting period of a few years such as 4 years and 6 years. In other words, a policy holder needs to hold the policy for a certain number of years before the maternity expenses are covered by the health insurance policy.
• Pre-Hospitalization Expenses: Pre-hospitalisation means relevant medical expenses incurred during a period up to certain (typically 30) days prior to hospitalization for an illness or bodily injury sustained and considered a part of a claim admissible under the policy. For example, a person maybe required to undergo certain tests to confirm the disease for which he or she is eventually hospitalized. The Doctor’s consultation fees for this, the expenses on tests and medicines prior to hospitalization for that particular disease fall under the category of Pre-hospitalization expenses. Typically, health insurance policies cover expenses for a certain number of days (most policies cover for 30 days) for Pre-hospitalization.
• Post-Hospitalization Expenses: Post Hospitalisation means relevant medical expenses incurred during a period up to certain (30, 45, 60 etc.) days after hospitalization for an illness or bodily injury sustained and considered a part of a claim admissible under the policy. Follow up consultations with specialists, medicines and test expenses after a person has been hospitalized and discharged fall under the category of Post-hospitalization expenses. Typically, health insurance policies cover expenses for a certain number of days (30, 45, 60 etc.) for Post-hospitalization.
• Emergency Ambulance Expenses: Costs incurred in transporting a insured patient to the hospital subject to limits and other conditions specified in the health insurance policy.
• Daily Cash for accompanying an insured child: If a insured child requires hospitalization, some policies provide daily cash to the accompanying adults.
• Domiciliary Treatment: These are costs incurred for treatment of patients at home. Most insurance policies cover domiciliary treatment if it is based on a doctor’s recommendation and within certain limits set under the health insurance policy.
• Spectacles, Contact Lenses, Hearing Aids: Typically covered only in premium policies.
• Outpatient Dental Treatment: Typically covered only in premium policies and only after a certain waiting period.
• General Health Checkup: Costs incurred for periodic health checkup that is not triggered by any illness. Typically policies cover this for a small (1 or 2%) percentage of the sum assured once every 2 or 3 years. Some of the medical tests covered by this include Medical Examination Report, Blood grouping and Rh Typing, Hb%, Blood Count, Fasting Blood Sugar, ECG and Urine Routine. Check with insurance company for complete coverage details.
• Cashless Hospitalization or Claim: If you have a health insurance policy that supports cashless hospitalization, it means that you can get medical treatment just by displaying your insurance card without paying any cash to the hospital. Most health insurance policies offer this benefit. However, the benefit is restricted to a certain list of hospitals specified by the health insurance company along with its policy. If you visit a hospital in-network (within the list provided by the health insurer), then you do not have to pay any cash for relevant medical expenses. You may still have to pay for expenses that are not covered by the policy rules. However, if you are admitted to a out-of-network hospital, you most likely will have to pay cash for your treatment. Depending on the policy, you may get reimbursed for such treatment by submitting a expense report to the health insurance company or its Third party Administrator (TPA). Cashless hospitalization or claim is a critical element of any health insurance policy.For cashless hospitalization, policies may require the Insured to contact the TPA at least 48 Hours before a planned hospitalization. In an emergency situation, the rules for when the TPA must be intimated may be different.

It must be noted that not all policies provide all of the above benefits. The benefit coverage amounts for each of the above may also vary based on the type of policy you have taken and the company from which you are taking the health insurance policy.

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