How to make claim from multiple health insurance companies?

Health Insurances 261 views

In the times of surging healthcare costs, a single health insurance policy may turn out to be highly insufficient. Just imagine you paid premium of your health insurance policy for two years. Suddenly, you had a kidney failure and it required a treatment that cost Rs 5 lacs. But the sum assured was Rs 2 lacs, much below the cost of the treatment. You got the cashless claim of amount say Rs 1 lacs and the remaining you borrowed from your friend for your treatment. Being associated with a single insurer prevented you from getting the full claim amount. So, it is always advisable to take policy from multiple health insurers to get the adequate cover and compensate for rejection of the claim by one insurer with the acceptance of another. These were simple benefits of multiple health insurance policies. But the most overriding question remains how one can make claims from such policies. All that has been explained below.

New regulations and its impact on your health insurance

The insurance regulator, Insurance Regulatory and Development Authority of India (IRDAI), has now removed the contribution clause to a great extent. With the contribution clause, earlier one had to notify all the insurers who would contribute to the total coverage in the ratio of sum assured. You can settle the insurance claims at any of the insurers. Suppose you bought the health insurance policy from two companies who provide the same sum assured value of Rs 5 lacs, then you can claim the amount from any of the two companies. But if the claim amount is more than the sum assured after taking into account deductibles, you will have to take a call on which insurer you should approach first. Thus, if the claim amount comes out to be Rs 6 lakhs, with insurer X and Insurer Y having sum assured of Rs 4 lacs. If the companies use contribution clause, then insurer X will give you 80%-90% and the rest 10% of the claim amount will be reimbursed by insurer Y.

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How should you approach claim process?

  • One should claim the amount from group health insurance cover first. You may have a group cover in addition to an individual plan. In that case, it will be better if you approach your group insurer first for the claim. Because, these policies feature less complicated clauses and have lower or no waiting period.
  • You can get the cover for pre-existing conditions or diseases from the very first day with the group health insurance plan, much unlike the individual plans where waiting period can extend from 30 days to a year. As a result, the claim process gets faster.
  • Future premiums are ineffectual from the number of claims that you would have made.
  • Further, if you manage to get the entire claim settled through the group cover, then the no-claim bonus (NCB), a situation where you do not make claim in a particular year, of your individual plan won't get affected during the time of policy renewal.
  • In case of having two individual health plans, you would be served better if you first claim through the old cover. It is because the waiting period of pre-existing conditions would most likely have been over with the older policy.

Claim process and its types

There are two types of claim process-cashless claim and reimbursement claim. During cashless settlement, the insurer offers you two documents-list of network hospitals and the identity card. The identity card provides contact details of the third party administrator (TPA), an organisation appointed by the insurer to intermediate between the hospital and the insurer for settlement of claims. Select any of the network hospitals for the treatment and the expenditure for the same will be borne by your insurer. If you wish to choose a hospital other than the network, then you will have to first bear the expenditure, get the bills of the same, send the bills along with necessary documents to the insurer to get the reimbursement. When you have to do multiple claims through reimbursement, then follow a list of steps mentioned below.

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Things to follow in reimbursement of multiple claims

  • Inform all the health insurance companies during the time of hospitalization
  • Choose the company from which you will claim first
  • Fill in the claim form
  • Get all the original bills and the required documents attached
  • Get more number of attested copies from the hospital for multiple insurers you are likely to claim from
  • A statement will be issued by the insurer saying they have settled the claims on having all the original proofs and documents
  • Once the claim gets settled by the first insurer, you then move to the next company. You must get a summary of claim settlement showing details of claim and deducations made, settlement of claim, etc, before moving to the next insurer.
  • Fill in their claim form
  • Get the claim settlement summary attached
  • Attach attested copies
  • Form a cover letter telling that you have earlier made a claim from company xyz, and send a details of necessary documents
  • Still if you want to claim from more health insurers, take the claim settlement document from second company as well and repeat the process mentioned above
  • The claim will get settled in a couple of weeks to a month.

Payment of claims

  • The first insurer will make the payment after applying deductions and limits against the claim made as per the terms and conditions laid down in the policy
  • The same process will be followed by the second insurer who will come out at a payable amount after deducting the amount received from the first company

So, this is what you need to do to get insurance claims from multiple health insurance companies.

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