Often, financially-savvy salaried employees have multiple, at least two, health insurance covers -- one provided by their employer and an individual cover they would have purchased on their own.
When it comes to filing claims during hospitalisation, the usual practice is to utilise the employer's group health insurance cover. This is a fair approach, as claim settlement processes under group health policies tend to be smoother.
Even if your policy comes with room rent sub-limits – which is typically the case – you can always claim the balance amount under your individual health policy.
Also read: How room-rent sub-limits can jeopardise your health insurance claims
In such cases, it is important to understand several nuances while filing claims under more than one policy.
Can I file claims under both group and retail health policies?
Yes. However, you cannot profit out of health insurance claims. Policies are meant to simply reimburse your actual hospital expenses. So, if you have two policies – a group cover of Rs 5 lakh and an individual policy with a sum insured of Rs 5 lakh – and your hospitalisation bill amounts to Rs 7 lakh, you can first exhaust the group sum insured by using the cashless facility. You can file a claim for the remaining Rs 2 lakh under your individual policy.
What if one policy makes a part-payment due to room rent or maternity sub-limits?
Typically, employers’ group insurance covers come with sub-limits on room rent. This is also the case with individual policies, unless you choose to pay higher premiums and buy capping-free covers.
For instance, say your Rs 5 lakh group insurance cover has a sub-limit of Rs 5,000 on room rent. However, you end up choosing a room where the rent is Rs 6,000 and spend five days in the hospital. This does not mean that you will have to shell out only Rs 5,000 more from your pocket.
Expenses such as doctor’s fees and nursing charges are linked to room rent. So, if your room rent is 20 percent higher, your approved claim amount will be reduced to this extent. If your claim amount in this example is Rs 5 lakh, the amount paid out to you will be Rs 4 lakh under the group policy.
The remaining Rs 1 lakh can be claimed under your second, independent policy. This calculation does not factor in expenses payable at actuals or the ones not linked to room rent.
Likewise, health covers come with maternity sub-limits ranging from Rs 35,000-Rs 50,000 for normal and C-section deliveries. So, if both the spouses are covered under, say, their corporate health covers to the extent of Rs 50,000 and their actual expense turns out to be Rs 90,000, both can file claims under their respective policies and claim the entire amount.
Also read: How to use Moneycontrol-SecureNow Health Insurance Ratings
What is the process to be followed while intimating the claim to multiple insurers?
Make sure you intimate all your insurers when you get hospitalised.
Due to operational challenges, hospitals usually ask you to pick one insurer for cashless claim settlement. You will need to file cashless claim with one insurer and claim the balance though the reimbursement route.
In such cases, after the claim is settled, ask the insurance company that settled the cashless claim to provide claim settlement letters. Use this and a photocopy of your treatment documents – certified by the first insurer - to file a reimbursement claim with the other insurer.
If you are filing reimbursement claims with all insurers, submit the claim forms and the original set of documents to the insurer you decide to approach first. The process for filing the second claim for the remaining amount will be similar: ask for certified copies of hospitalisation bills. The insurer will also give you a claim settlement letter. This letter, or voucher, will contain details of the amount settled.
Submit these documents along with another set of claim forms and present the application for the remaining claim to the second insurer. If both of your policies are with the same insurer or the third-party administrator (TPA), the process will be simpler.
What if I hold one indemnity or regular (reimbursement-based) cover and another pre-defined or fixed benefit policy?
Benefit-based or fixed-benefit policies pay out the entire sum insured, upon diagnosis of ailments specified in the policy contract. Typically, these are dreaded disease covers – for instance, critical illness covers offered by non-life insurers and criti-care riders or cancer policies sold by life insurance companies. These policies can complement regular, reimbursement policies as you can file claims under both covers.
One will help you recover your hospitalisation cost and the fixed benefit cover make good any loss of income during the recuperation period or cost of any equipment that you may need to buy. The claim process in case of fixed-benefit policies is relatively simpler: you simply need to submit photocopies of treatment bills as proof of contracting the illness and the sum insured will be paid to you.
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