How to Make Multiple Health Insurance Claims

Consequently, despite the availability of corporate insurance, individuals increasingly opt for additional coverage through avenues such as Individual Health Insurance, Family Floater Health Insurance, Critical Illness Insurance Coverage, and Top-up Plans.

Yet, despite this trend of buying multiple health policies and their benefits, many policyholders find themselves clueless about the complexities of making claims across multiple health insurance plans.

This article elucidates the process of making multiple health insurance claims, providing a comprehensive guide on leveraging multiple health insurance policies to maximise benefits effectively.

In order to help policyholders optimise the benefits of multiple health insurance plans, the Insurance Regulatory and Development Authority of India (IRDAI) has implemented revisions to the governing rules and regulations. Before 2013, the IRDAI mandated that the total medical expenses must be apportioned among insurance companies based on the sum assured by each. This provision, termed the 'Contribution Clause' in health insurance, required proportional sharing of expenses.

However, this requirement has since been eliminated, granting policyholders the freedom to approach any single insurer to process their claim. Yet, the question remains: how does one navigate the process of claiming from two or more insurance companies?

[Also Read: From Clicks to Coverage: The Benefits of Online Health Insurance Shopping]

Is It Possible to Get a Claim from Both the Insurance Companies?

If you have both corporate health insurance and a personal health insurance policy, you might wonder if filing claims with two insurance companies is possible. The answer is "Yes".

To initiate a claim with multiple health insurance plans, you first submit it to the first insurance provider for coverage of medical treatment expenses. Subsequently, you get a summary of the claim settlement, verify hospital bills, and proceed to approach the second insurance company to cover the remaining expenses.

Here are some suggestions for processing claims with multiple health insurance policies:

1. When Choosing from the Indemnity Plans:

When choosing between Indemnity Plans, individuals typically opt for health insurance policies that reimburse actual medical expenses incurred during treatment rather than providing fixed benefits plans. These policies, such as individual health insurance plans, family floater health insurance plans, or senior citizen health insurance plans, operate on this principle.

However, it's important to note that Indemnity Health Insurance Policies don't allow multiple claims for the same medical expense. For instance, if you have two health insurance policies from different companies, each offering coverage of Rs 3,00,000, and your medical treatment totals Rs 4,00,000, you can only claim a maximum of Rs 3,00,000 from one policy. You cannot claim Rs 3,00,000 from each policy despite the combined sum insured being Rs 6,00,000.

However, if your medical expenses exceed the sum insured by one policy, you can claim the entire sum insured from one policy and the remaining amount from another. Therefore, the decision on which policy to use should be based on the claim amount and sum insured.

In the above scenario, if one policy offers a sum insured of Rs 3,00,000 and the other Rs 4,00,000, it's more sensible to utilise the policy with the higher sum insured instead of claiming from both policies.

2. When Deciding Between Indemnity Plans and Fixed Benefit Plans:

In recent years, Fixed Benefit Health Insurance Plans have gained popularity. These plans offer a predetermined sum assured to policyholders upon diagnosis of specific illnesses, regardless of the actual medical expenses incurred.

Examples include Cancer Care Policies, Critical Illness Covers, COVID Rakshak Policies, etc., which provide a fixed benefit (sum assured) upon diagnosis. Conversely, Indemnity-based health insurance covers the actual medical expenses.

When faced with the choice between an Indemnity-based and Fixed Benefit Health Insurance Plan, it's possible to claim benefits from both policies if they align with the terms and conditions stipulated in each policy.

[Also Read: All You Need to Know About Claim Settlement Process of Health Insurance]

3. Select an Employer Plan Over a Personal Insurance Plan:

Salaried individuals often receive health insurance coverage through corporate plans provided by their employers. However, many individuals also opt for personal health insurance plans to ensure adequate coverage for themselves and their families.

When deciding between an employer plan and a personal plan, it is advisable to use the corporate plan first. Corporate health insurance plans typically offer more extensive benefits than individual plans.

Additionally, using the corporate plan allows policyholders to benefit from the No Claim Bonus for their personal plan or maintain coverage for family members, which might not otherwise be possible. Furthermore, using the corporate plan initially is prudent, especially considering that changing employers renders the plan unusable.

4. Choose an Individual Plan First:

When faced with the choice between an individual health insurance plan and a family floater plan, it's best to use your individual plan first. By doing so, the coverage of the family floater plan remains available for your family members. This ensures they have sufficient coverage in case they need to make substantial claims.

5. Utilise Your Basic Plan Before a Top-up Plan:

If you have both a basic health insurance plan and a top-up health insurance plan, it's important to understand that top-up plans typically come with a higher deductible clause. They are intended to be utilised after exhausting the coverage of the basic plan. Therefore, there should be no confusion regarding which plan to choose first when making a claim.

6. Considering the Co-payment Clause:

While the claim amount, sum insured, and type of plan are crucial factors in deciding which policy to use first, they should not be the sole criteria. It is possible that your health insurance policy with maximum coverage also includes deductibles or a co-payment clause, which might be financially burdensome.

Deductible refers to the claim amount the policyholder must pay before the insurance company starts covering healthcare expenses. Co-insurance is a fixed percentage of the claim amount the policyholder must pay out of pocket. It is advisable to prioritise policies with zero or low deductibles and co-payments to avoid paying significant amounts out of pocket before the insurance company starts covering claims.

[Also Read: 8 Top Reasons Why Health Insurance Claims Get Rejected and How to Prevent Them]

7. Prefer Cashless Claim Settlement:

A cashless claim facility allows you to get cashless hospitalisation at the network hospital without paying from your pocket. Although cashless claims offer convenience at network hospitals, there might arise instances where you require treatment at hospitals outside the insurer's network. In such cases, you'll need to settle the claim using the reimbursement method.

It makes sense to take advantage of the cashless claim process as you will not have to pay for hospitalisation from your pocket and wait for reimbursement from the insurer.

To conclude:

While holding multiple health insurance policies provides enhanced coverage and benefits, choosing the right policy for the initial claim significantly impacts the remaining coverage. Therefore, it is essential to consider the abovementioned factors when choosing a policy for making a claim.

Additionally, factors such as ease of claim, cashless vs reimbursement claim, claim settlement process, insurer services, policy terms and conditions, etc., should also be weighed to facilitate a smooth claim settlement process.

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KETKI JADHAV is a Content Writer at PersonalFN since August 2021. She is an MBA (Finance) and has over seven years of experience in Retail Banking. Ketki specialises in covering articles around banking, insurance, personal finance, and mutual funds and has been doing it for over three years now.

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