Mar 27, 2009

Health (Mediclaim) Insurance Policy - Coverage & Exclusions

Before buying a health insurance policy (popularly known as mediclaim policy), you should be aware of some basic features like what does the health (or mediclaim) policy cover and what it does not cover? This post tries to provide you a brief but comprehensive overview of the basic features of the coverage provided by various health / mediclaim insurance policies available in India as of now.

Coverage: Restrictions & Limitations

1. Maximum Cover
Most insurers have put a maximum cap of Rs 5 lakh on the sum insured except for a few insurance companies such as Apollo DKV, Bajaj Allianz, Cholamandalam MS General Insurance and Star Health and Allied which provide coverage up to Rs ten lakh.

2. Sub-limits
Now-a-days, most mediclaim policies come with sub-limits on various expenses like room rent, doctor’s fees, diagnostics etc. For instance, National Insurance Company (NIC) under its Mediclaim Insurance Policy (Individual) has imposed room rent limit of 1 per cent of sum insured per day subject to a maximum of Rs 5000; however, if admitted in ICU the room rent limit is two per cent per day and maximum limit becomes Rs 10,000. Furthermore, the mediclaim policy of NIC also stipulates that total of room, boarding and nursing expenses can’t exceed twenty five per cent (25%) of the sum insured per illness.

What are its implications? Put simply, you’re not allowed to claim more than the stipulated amount under any specific head. It also means that you may have to foot the medical bill partly even if the total bill is below the sum insured. For Instance, if your health policy sum insured is Rupees two lakh, room rent expenses will be allowed only to the extent of Rs 2,000 per day (in the above mentioned mediclaim policy of NIC). Any room rent expenses beyond this would have to be borne by you.

3. Hospitalisation
Usually a minimum hospitalization of 24 hrs is required for filing a claim under mediclaim policies.

However, for certain medical treatments (Day Care Treatments) and minor surgeries the limit of 24 hrs hospitalization is waived off. For example, Apollo DKV Easy Health policy covers medical expenses for 140 day care procedures which do not require 24 hours hospitalisation due to technological advancements.

A few such treatments as per Mediclaim Insurance Policy (Individual) of National Insurance Company (NIC) are listed below:

a. eye surgery
b. dental surgery due to accident
c. dialysis
d. Coronary angioplasty and angiography
e. Kidney stone removal
f. Treatment of fractures / dislocations excluding hairline fractures
g. Surgery of Appendix, Gall Bladder, Pancreas, Bile Duct, Hernia, Prostate and ENT
h. Radiotherapy.

4. Pre & Post Hospitalisation cover
Besides hospitalization expenses, most healthcare policies also allow you to claim relevant medical expenses incurred during 30 days prior to hospitalization and 60 days after hospitalization.

A few healthcare policies provide wider coverage like Chola Health Insurance Plan covers 60 days prior to hospitalization and 90 days after hospitalization.

5. Domiciliary Hospitalization
Domiciliary hospitalization means the medical treatment is done at home for a period exceeding 3 days for any ailment or injury, which otherwise would require hospitalisation, due to either non-availability of accommodation in the hospital / Nursing Home or if the condition of the patient is such that he cannot be moved to a hospital.

Only a few insurance companies allow domiciliary hospitalization. For instance, while Reliance Health Care Policy and Apollo DKV Easy Health policy allows domiciliary hospitalisation, Bajaj Allianz, ICICI Lombard and National Insurance Company exclude it from the coverage.


It is always better to know beforehand various exclusions and limitations about the mediclaim policies so that you’re aware of the exact scope of the policy coverage to avoid the disappointment later at the time of making a claim. Some of the common exclusions (although vary from policy to policy) are as follows:

6. Waiting Period
Almost all Healthcare or Mediclaim policies carry a waiting period usually of 30 days. Put simply, you can’t make any claim for any diseases contracted within 30 days of buying the health / mediclaim insurance. However, accidental injuries are covered from day one i.e., waiting period is not applicable in case of hospitalization / surgery due to accident.

7. Pre-existing diseases
A fresh mediclaim policy doesn’t cover pre-existing diseases. They get covered only if you don’t make any claim for 4 or 5 consecutive years. In other words, pre-existing diseases gets covered usually after 4 or 5 continuous claim free years.

For example, while National Mediclaim policy, United India Mediclaim, Apollo DKV Insure Health and Bajaj Allianz Health Guard cover pre-existing diseases after 4 claim free years, Royal Sundaram Alliance Health Shield Standard, ICICI Lombard Comprehensive Health and Bajaj Allianz Insta Insure cover them after 5 claim free years.

However, there are exceptions also, for example Reliance Individual Mediclaim (silver plan) and ICICI Lombard Health Advantage Plus covers pre-existing diseases after second year (i.e., from third year onwards), and Apollo DKV Easy Health covers them after a period of 3 years.

8. Temporary Exclusions
There are certain diseases which are covered after 1 or 2 years.

For example, Medi-Classic Individual Policy from Star Health and Allied Insurance Company Limited excludes Hysterectomy, Hydrocele, Hernia, Piles, Sinusitis, Gall stone and Renal Stone removal / treatment etc during the first year AND also exclude Cataract, Joint Replacement Surgery etc during first two years.

In contrast, Mediclaim Insurance Policy from NIC excludes (in addition to other temporary exclusions) all the above ailments (except Joint replacement surgery) during first two years. Besides, it excludes Joint replacement due to degenerative conditions, age related osteoarthritis and osteoporosis during first 4 years of policy.

Similarly ICICI Lombard Health Advantage Plus also excludes (in addition to other temporary exclusions) all the above mentioned medical conditions or treatments during first two years.

9. Permanent Exclusions
There is a long list of ailments that are excluded from the purview of mediclaim policies. Here’s a list of few such general ailments and medical treatments which are not covered:

a. Dental treatment except arising out of accidents.
b. Pregnancy and child births
c. OPD expenses
d. Naturopathy, alternative medicine/treatments including acupressure and magneto-therapy etc.
e. Sexually transmitted diseases (STD) and AIDS
f. All psychiatric disorders
g. Circumcision, cosmetic surgery, plastic surgery unless required to

This is only an indicative list. Further, there are many exceptions to the above list, for example, Medi-Classic Individual Policy from Star Health and Allied Insurance Company Limited allows for treatment under alternative system of medicines (except Naturopathy treatment) but is limited to 25% of the sum Insured, subject to a maximum of Rs 25,000 in the entire policy period.

Similarly, ICICI Lombard Health Advantage Plus also allows OPD expenses, dental treatment etc (but subject to limits specified).

10. Overseas Medical treatment
Medical treatment abroad is also not covered under the health / mediclaim policies.

Also see:

1. Mediclaim vs Critical Illness - Know the Difference
2. Health / Mediclaim Insurance - 10 Practical Tips
3. Why You Need to Continue Your Existing Mediclaim Policy
4. Life Insurance Policies - 7 Basic Features


  1. Good article. But hard to derive any conclusion which one to opt for.

  2. Should have compared all the plans avialable in India. Over all good information.

  3. Hi,thanks for the informative article on health insurance. one should definitely be sure of what he is going to buy is a good & effective policy which could provide him good covers.I think people must take help of these online tools which helps them to plan their insurance.Please check this out at-

  4. pls let me know is U.T.I covered under mediclaim ploicy in 2nd year.tell me at

  5. sir,
    please give a comparision of good medicjaim schemes to facilitate us taking right decisions.

  6. Sir.. Thanks.. I got a good idea about the mediclaim plan after reading this article.


  7. I have a apollo dkv health insurance policy for my family of 3(floater) and indiviadual plan for my mom and sister.Is it a good mediclaim policy or should I switch to some other policy as I have to take a new policy for everybody...pls advice

  8. hi fisher,

    Is there any policy which only covers medical bills due to accidents only along with accidental death benefits.


  9. The only blog which covers topic so comprehensively that all your doubts are clear!
    Well done Fisher. You did a great job



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