How To Choose Right Mediclaim Policy In India, A Doctor’s Guide For The Common Man

Over decades of clinical practice, what disturbs Dr. Vijay Kumar Agrawal, Senior Pulmonologist and Critical Care Specialist at Yatharth Hospital, Faridabad, is not only the physical suffering of patients but also the silent financial distress that often accompanies illness. Patients struggle with breathlessness, pain, and fear, while families grapple with an equally paralyzing concern—whether they can afford the treatment their loved one needs.

“In many cases, financial anxiety enters the consultation room uninvited,” Dr. Agrawal says in a conversation with the Health Outlook. “It influences decisions, delays treatment and sometimes compromises outcomes.”

“Earlier, families depended on savings, loans or relatives during illness. In today’s high-cost medical environment, that approach is increasingly risky and inadequate. Mediclaim is no longer optional; it is an essential component of healthcare planning—much like vaccination, regular health check-ups and healthy lifestyle choices,” he adds.

However, patients and families often approach health insurance only after a major illness has already struck—when exclusions apply and choices are limited, Dr. Agrawal notes. Mediclaim, however, is not designed to be a last-minute rescue; he argues that it is “a safety net that must be put in place well before illness appears.”

Yet, choosing a mediclaim policy in India remains confusing for most people. Policy documents are technical, conditions are buried in fine print, and marketing claims frequently overshadow medical realities.

To begin with, why has mediclaim become a medical necessity? Dr. Agrawal reiterates that India’s healthcare system has made remarkable progress with advanced diagnostics, modern intensive care units, minimally invasive surgeries, and effective medicines that have significantly improved survival and quality of life. “But these advances come at a steep cost,” he says matter-of-factly.

For instance, “a single day in an ICU can equal a month’s income for many families. Investigations such as CT scans, MRIs, angiography and biopsies are expensive. Chronic diseases demand lifelong care, and medical emergencies are unpredictable.”

When asked what mediclaim is—and what it is not—Dr. Agrawal explains that mediclaim is a financial support system, not a medical one. It does not cure disease or decide treatment. What it does is remove financial barriers, allowing patients and doctors to focus on timely and appropriate care.

Equally important, he says, is understanding what mediclaim is not. It is not a savings scheme, not an investment product, and not a solution for advanced illness acquired before purchase. It works best when viewed purely as protection against risk.

However, Dr. Agrawal cautions that individuals must understand their health profile before buying a policy. “Like doctors never prescribe treatment without examining a patient, insurance selection should also follow the same principle. Age, existing conditions such as diabetes or hypertension, family history of heart disease or cancer, lifestyle factors like smoking, and whether one lives in a metro or non-metro city—all influence healthcare risk.”

For instance, he notes, a 28-year-old professional and a 65-year-old retiree face very different medical problems. A good mediclaim policy must reflect the stage of life and health profile of the insured.

Choosing the right sum insured is another critical decision, he points out. “One of the most common mistakes is opting for low coverage to reduce premium costs. Coverage of Rs 2–3 lakh, once considered sufficient, is now medically inadequate in many situations,” Dr. Agrawal says.

“ICU admissions, cardiac procedures, cancer treatment and complicated surgeries can easily run into several lakhs. From a clinical perspective, younger individuals should consider at least Rs 10–15 lakh. Families with children need higher cover, while senior citizens often require Rs 20 lakh or more. Medical inflation rises faster than salaries, and insurance must keep pace.”

People can opt for a family floater or an individual policy, he suggests. Family floater policies are cost-effective for young families but carry medical limitations. If more than one member is hospitalized in a year, the shared sum insured can be used quickly. Elderly parents or those with chronic illness are medically safer under individual policies, he emphasizes.

Dr. Agrawal also made it clear that mediclaim does not cover everything immediately. Waiting periods apply for initial coverage, pre-existing diseases, and certain conditions such as cataract or joint replacement. “This is why it is advised to buy insurance early.”

Equally crucial is honesty. All existing illnesses must be declared. Concealment may reduce premiums initially but often leads to claim rejection later. Transparency protects both patient and insurer, says Dr. Agrawal.

So, what clauses should one pay close attention to? Dr. Agrawal says room rent limits and ICU sub-limits significantly affect claim settlement. Opting for a room category above eligibility can trigger proportionate deductions across the entire bill. One should opt for policies with no room rent limits or, at least, eligibility for a single private room.

Cashless treatment is another critical feature. During emergencies, it reduces stress, speeds up care, and allows families to focus on recovery rather than paperwork, says Dr. Agrawal.

What, then, is his final message? “Illness is unpredictable, but preparation is not. Mediclaim does not prevent disease, but it prevents panic, delay and compromise. Buy early. Buy adequately. Read carefully. Insurance taken in good health becomes a quiet blessing during bad health,” he asserts.

Dr. Vijay Kumar Agrawal, Senior Pulmonologist and Critical Care Specialist at Yatharth Hospital, Faridabad