Source: DNA India
Have you been facing the
problem of plenty when it comes to health insurance plans – Employer's health
policy, various 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 tend to be
lenient toward many clauses and claiming from group covers such as health
insurance provided by employer, or health insurance offered to club members,
etc. 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 under group insurance policies. 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
apart from the individual cover 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 in India 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 multiple individual health
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 submit 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, 2013, 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
area to deal with as hiding information would be considered fraud and 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 citing
fraudulent intentions. 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 for the balance amount
too 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. So, if you have a top-up cover that would kick in only for claims
above Rs 3 lakh, then you would have to claim the hospitalisation bill of Rs
1.5 lakh from the individual policy, and no claim would be permissible under
the top-up. 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."
How to avoid a long
wait for your claims processing?
To avoid wastage of time while
waiting for one insurer to respond and then file a claim with the other, you can
take the following steps:
Read policy document and watch
out for states exclusions, which won't be covered under the policy.
Calculate the waiting period
for select diseases and claims and assess whether you have completed them.
The document would also state
the pre-existing disease waiting period, which would be for the diseases you
have disclosed at the time of policy purchase. The waiting clause is for 2-4
years typically from the policy start date.
When applying for a health
insurance policy, you should disclose the details of the existing policies that
you hold in the proposal form. Several insurers are bound by a contribution
clause, wherein the claim would be shared between the two insurers depending on
the proportion of the sum assured.
If you plan to claim from two
policies, claim under the policy where sub-limits are applicable first. Thus
you would know the deductions made for various heads such as room rent,
doctors' fees, etc. The second insurer, which doesn't apply many limits, would
then be free to reimburse to the balance extent.
When seeking increase in cover,
you can opt for top-up/ super top-up plans or increase in sum assured under the
same policy at the time of renewal to avoid the hassle of claiming from
multiple small covers.
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