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You cannot make a claim for same hospitalisation to both the companies as you cannot profit from health insurance. However, there may be situations when you can claim from both the policies
Have you been facing the problem of plenty when it comes to health insurance – Employer’s health policy, individual plans, office cover of your spouse? People looking for a higher sum assured to tide over rising healthcare costs often seek fresh health insurance policies.
But the predicament of which policy to file the claim under emerges. The answers to how one could manage claims from multiple insurance policies would have been different and confusing prior to 2013. “Simplified procedures and situations have been clarified via the Health Insurance Regulations notified in February 2013,” says Sudhir Sarnobat, founder and director at Medimanage Insurance Broking.
We here detail the options available and the procedure to make a claim from multiple health policies under varied situations:
Group versus individual
Group policies such as health insurance provided by employer tend to be lenient toward many clauses and claiming from group covers. Many also cover pre-existing diseases from the first day. The chances of a steep rise in premium after making a hefty claim during the previous year too are low. The limits per surgery or hospitalisation such as Rs 25,000 for cataract, Rs 35,000 for maternity claim are a little relaxed for group insurance policyholders. So, if you have a group policy, then it makes sense to make a claim under the group cover first.
Multiple individual policies
Those who don’t belong to the organised workforce are likely to have multiple health covers, for instance a self-employed who has taken two policies of Rs 3 lakh and Rs 5 lakh each as he thought the first one would be insufficient. Such policy owners should weigh the options based on parameters such as cashless facility, whether the chosen hospital falls under the network, the sum assured, whether the surgery or reason for hospitalisation would be permissible in lieu of waiting period, exclusions, specified limits for select surgeries and caps (sub-limits) on room rents applicable under both policies. You cannot make a claim for the same hospitalisation to both the companies as you cannot profit from health insurance. However, there may be situations when you can claim from both. For instance, if Suresh has two health plans for a sum assured of Rs 5 lakh (A) and Rs 3 lakh (B) and his medical bill runs to Rs 6.5 lakh, then he would have to make a claim under both the policies.
An easier way out is to make a claim with one insurer and mention the details of the other health plan. The insurance companies have a contribution clause in place, where each company has to share the claim based on the proportion of the sum assured for the same claim. “If the amount of claim exceeds the sum insured under a single policy after considering the deductibles, co-pay, the policyholder shall have the right to choose insurers by whom the claim should be settled, In such cases the insurer may settle the claim with contribution clause,” state the Health Insurance Regulations, 2013.
So, you should submit all the hospital documents to the first insurer. Attested copies or certified duplicate bills can be submitted to the other insurer for the balance amount. However, if Suresh has to foot a bill of just Rs 1.5 lakh, then he can take a call on which health plan should he claim from. It would be better to claim from the insurance plan where he has made a claim earlier as he can gain no-claims bonus on the other.
The Health Insurance Regulations permit the individual to claim under just one policy, without implementing the contribution clause, “If two or more policies are taken by the insured during a policy period from one or more insurers to indemnify treatment costs, the insurer shall not apply the contribution clause, but the policyholder shall have the right to require a settlement of his claims in terms of any of his policies.”
What do you do if insurer A asks for details of any other insurance cover that you own? This is a tricky as hiding information would be considered fraud. Hence, you should always disclose the details when asked. If you avoid disclosing and the company later finds out, then they have the right to deny the claim. As a result not alone this particular claim would be affected, but the company may even take the harsh step of stripping you off the health cover.
Claim denied
If one of the insurers has rejected your claim, you can apply for claim at the other insurance company. Similarly, if one insurer has partially paid the claim based on the room rent caps, doctor fees ceiling, policy exclusion etc., then the balance amount can be filed for a claim with the other insurer. Here too attested copies of documents can be submitted citing the details of amount cleared by the first insurer.
Top-up covers
When you have an individual cover and a top-up cover to claim from, then the decision is fairly simple. You cannot claim from the super-top top up cover unless the threshold limit is exhausted. If you wish to increase your health insurance coverage top-up policies would be a cheaper alternative than purchasing a new health cover altogether.
Different types of covers
There are health insurance plans offered by life insurance companies (fixed benefit) and even critical illness plans where the policyholder is given a lumpsum amount when any listed severe disease strikes. If you own one of these plans apart from the general insurer’s hospitalisation policy, then you are permitted to make a claim under all, keeping in view the high treatment costs you would have to bear post hospitalisation. The clauses of these plans are different, but the thumb rule that one should not benefit from insurance stays put. Even the official gazette has permitted insurers providing fixed benefit plan to make payments without taking into account payments made under other indemnity plans. It notifies, “In case of multiple policies which provide fixed benefits, the insurer shall make the claim payments independent of the payments received under other similar policies.”
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