How to make a Health Insurance claim with multiple policies

In India, not many people have health insurance coverage, but those who have it are usually covered by at least two insurers. The reason behind getting two health policies can be to get an adequate coverage as the cost of medical treatment is constantly on the rise, and most medical insurers refuse to provide cover beyond a certain sum. There may be other reasons such as taking a special policy for kids, or that an individual just prefers to have separate policies for his/her parents and spouse. In many cases, there’s also the group mediclaim cover provided by the employer.

But what many fail to understand is that buying two medical policies doesn’t solve the problem, as a minor mistake while filing the claim can result in reduced claim settlement amount. You need to know how to properly file a claim and use multiple policies to your advantage.

Health insurance companies require you to make a disclosure in their proposal forms about any other medical policy that you are holding. Not disclosing this fact can lead to violations of terms and conditions of the insurer, and can create a hassle at the time of claim filing.

The main reason why one should disclose any existing health insurance plans when buying a new one is the “contribution Clause”. This clause states that based on the liability of the insurers when there are two policies for the same “insured interest”, a claim would require the insurance companies to contribute to the settlement amount in the ratio of the sum insured.

For example, a person holds two policies with a cover of Rs. 2 Lakh and Rs.1 Lakh, respectively. If the person makes a claim of Rs. 50,000, the insurance companies will pay Rs. 33,333 and Rs. 16,666, respectively as the claim amount.

*Please note that the example above is purely for the purpose of understanding, and does not represent the calculation of the claim amount in such an arrangement

Also, a person holding two policies has the option to file claim with any one of the insurers. For example, if a person holds an individual health policy and a group health insurance, he has the choice of filing his claim with either of them.

A very important point to note in this all is that the contribution clause only comes into play when the amount claimed is more than the insured sum. The change in health insurance regulations now requires you to inform the health insurance company only if the amount claimed is more than the sum insured for.

There are a few things that must be kept in mind when filing a claim with two insurers. First of all, inform all the insurers of the hospitalization. For cashless claims, you can make a cashless claim on one of the insurer and get the claim settlement summary. After getting this done, you need to get the attested copies of the hospital bills and approach the second insurer to request the reimbursement of the remaining amount. If you get a clearly defined cost of treatment from the hospital, you can just fill the authorization forms. With the hospital sending the filled up form to each of the health insurance providers, the matter will then be sorted out by the insurance companies directly with the hospital, according to the terms of the policies.

While cashless claims have become the norm, there are many hospitals that do not provide cashless facility. In such cases, at first, you will need to pay the bill out of your own pocket and have it reimbursed later by your health insurance provider. For making a claim, you will be required to submit the original bills to your preferred health insurance provider. The insurer will reimburse the amount as per the terms and conditions. To file a claim with the second insurer, you need to get the claim settlement summary and file it along with the claim form. The second insurer will then settle the remaining amount according to the terms and conditions of the policy.

When the claim is filed with the first insurance company, the amount settled by the insurer is calculated after accounting for any deductibles or co-pay. Also, when filing a claim in case of multiple policies, the first choice for claim filing should be the older of the two policies, which will be past the waiting period for most of the diseases covered. Also, as a guiding principle, the insured should read all the terms and conditions of the insurance policies carefully to be fully aware of the coverage provided by the plans.