Manoj met with an accident due to which he had to undergo several surgeries and spend 21 days in the hospital. At the time of discharge, he was handed a bill of INR 8 lakhs. Manoj had two health insurance plans, each with a coverage amount of INR 5 lakhs and INR 3 lakhs and respectively. He made a claim of INR 5 lakhs from the first insurer and the remaining from the second. The first claim was a cashless settlement while the second claim had to be reimbursed. Manoj was happy with both the settlements as apart from the copay and deductible, he did not have to pay a single paise from his own pocket.
This is a huge benefit he got from having two health insurance plans that allowed him to make multiple claims. If you too have multiple health insurance covers, you should be aware of how to use the plans simultaneously so that even if you have a large claim amount, you can get it processed smoothly. Read on to know more.
What are Multiple Health Insurance Claims?
When the claim amount exceeds the total limit of a single health insurance policy, the same can be claimed from 2 or more different insurance policies, across multiple insurers as well. Previously, the contribution clause was effective whenever multiple claims were concerned.
What is the Contribution Clause?
The meaning of the Contribution Clause is when a health insurance claim needs to be done from more than one insurance policy, all the policies will “contribute” to the claim in equal proportions to the total sum insured.
Let’s see the explanation with an example:
Manoj has 2 health insurance policies of INR 5 lakhs from Policy A and INR 4 lakhs from Policy B respectively.
|Claim situations||Claims from Policy A and Policy B under Contribution Clause||Claims from Policy A and Policy B without Contribution Clause|
|Situation 1: Total Claim INR 90,000|
INR 50,000 would be paid from Policy A and INR 40,000 would be paid from Policy B in the proportion of the total sum insured.
Claim Payable = INR 90,000(total claim amount) / INR 9 lakhs (total sum insured across both plans) X sum insured of the specific plan
|INR 90,000 can be claimed from either Policy A or Policy B (since both are less than the total sum insured)|
|Situation 2: Total Claim INR 8 lakhs||INR 4.44 lakhs (8/9 X 5) would be payable from Policy A and INR 3.56 (8/9 X 4) lakhs would be payable from Policy B|
If Policy A is claimed first, then upto INR 5 lakhs can be claimed from policy A and the remaining amount of INR 3 lakhs can be claimed from policy B.
If Policy B is claimed first, then upto INR 4 lakhs can be claimed from Policy B and the remaining INR 4 lakhs can be claimed from Policy A.
However, the contribution clause for health insurance claims is not applicable anymore. So, the policyholder can decide which policy to claim from based on multiple factors like:
- Ease of claim
- Co-payment and room rent limit
- Group and Individual health insurance plan and the possible NCB loss
- Renewability clause
- Associated benefits
- Documentation and cashless facility, etc.
Is it Possible to have Multiple Health Plans?
Yes, it is quite possible for anyone to have multiple health insurance plans. When you need to make multiple claims, there are a few things you should keep in mind:
- Coverage amount and Benefits
You need to bring out your calculators and see which health plan has what cover. The volume of coverage on every plan you have may not be the same, so you need to make proper claims, based on the available cover.
For example, if your hospital bill is INR 5 lakhs and a particular health plan only has a coverage of INR 3 lakhs, you cannot make your entire claim from it. You will then have to spread out the claim amount over all the health covers you have.
- Primary Claim
Choose the health plan on which you will make the first (and possibly the larger) claim. You need to decide this, especially if you want to go for a cashless settlement. The secondary claim would then be processed accordingly. So decide where you want to make the first claim for and go about the process accordingly.
- Acquired Benefits
Every claim you make will have an effect on the acquired benefits such as the no claim bonus, the waiting period, pre and post hospitalisation expenses, etc. This is something you need to keep in mind when deciding whether you want to make multiple claims or a single claim.
- Looking Towards Your Group Cover
If you have a group health insurance cover, you can try making a large claim on that policy. This is because a group health plan has fewer exclusions and clauses such as the waiting period are usually more relaxed. Also, you do not have a No Claim Bonus is a group plan. So, there is no option of losing the same as well.
Then, there are no worries about losing the acquitted benefits on such a cover. It is therefore advisable to make a larger claim from your group cover and then the remaining amount from your individual cover.
The documents will be needed by both the insurers. Since you will be submitting the original documents to the health insurance company from where the first claim is made, ensure you make proper photocopies of the original bills and memos before you submit them.
Keep these crucial points in mind before making a claim as it will make it easier for you to choose the perfect cover and also make the most effective claims.
Types of policies that can be utilised for Multiple Claims of health insurance in India:
All permutations and combinations can be used for filing of multiple health insurance claims in India like:
- Two or more indemnity individual health insurance plans
- Two or more group indemnity health insurance plans
- One or more group and one or more individual indemnity health insurance plans
- One or more Indemnity health insurance plans along with one or more top-up or super top-up indemnity health insurance plans
Claims for all possible combinations are possible and the process for applying for them is identical. Only claims from fixed benefit health insurance plans are different from indemnity health insurance plans as there is no connection between the two. They can be claimed independently and don't depend on each other.
The Process Involved in Multiple Claims
How exactly does the claim process work when you need to make multiple claims for a single account? Here are the steps:
Cashless Claim on First Policy and Reimbursement of the Second
- Cashless of the First
If you choose to go for a cashless claim on the first policy, follow the regular process of intimating the insurance provider before getting admitted, submitting the authorisation form and informing the TPA. Then, go for the claim amount you want. You need to inform the insurer specifically about the amount.
- Pay the Remaining
After the claim is settled, you have to pay the remaining amount from your own pocket. Keep track of all the payments made as you have to get the amount reimbursed from the next insurance company.
Tip: Remember to collect “Certified True Copies” of all the original documents submitted to the primary insurer for the claim, so that it can be duly submitted to the subsequent insurer as well.
- Reimbursement on the Remaining
For the remaining amount that you yourself paid, you need to make a reimbursement claim from the second insurance provider with whom you have a health insurance plan. You need to get a detailed claim settlement copy from the first insurance provider. This is an important document needed as it mentions how much has been paid and what the balance amount is. Then, you will also need to submit the required documents. Once that is done, the insurance provider will verify your application and reimburse the amount.
Tip: The secondary reimbursement can be accompanied by pre-hospitalisation and post-hospitalisation expenses as well.
- Cashless Claim for Both the Plans
- Cashless of the First
Once you decide on the primary insurer, you need to apply for a pre-authorisation from the primary insurance company. Once the approval comes in and you feel that the expenses would surpass the total limit of the primary insurer, you can file for a pre-authorisation from the secondary insurer as well. Both the claim intimations can be processed simultaneously from the hospital’s TPA desk.
- One by One Processing of Claim
On discharge, the claims would be settled one by one so that there is no duplicacy and ambiguity.
Note: Since the claims can ONLY be processed one after another, the time taken for the entire process to be completed can be quite long and it may eventually delay the entire discharge process.
- Pre and Post Hospitalisation Reimbursement
The pre-hospitalisation and post-hospitalisation expenses would anyways need to be filed separately as a reimbursement as there is no process for cashless settlement of the same.
- Cashless of the First
- Reimbursement of Both the Plans
- Reimbursement from the Primary Insurer
Once you decide on the primary insurer, you need to send all the documents to them along with a claim form for the reimbursement.
- Certified True Copies
Once the reimbursement is processed successfully, you need to apply for ``Certified True Copies” of all the original documents submitted to the primary insurer for the claim, so that it can be duly submitted to the subsequent insurer as well.
- Subsequent Reimbursement Claim
For the remaining amount, which hasn’t been paid by the primary insurer, along with Certified True Copies” of all the original documents and the claim form, you need to submit it to the secondary insurer for reimbursement. This can be done along with the claim for the pre-hospitalisation and post-hospitalisation expenses as well.
- Reimbursement from the Primary Insurer
Follow these simple steps and your health insurance claims will be paid out without too many difficulties.
The insurance industry is very customer-friendly and the laws and rules have been made to make the processes very smooth and convenient for the policyholders. This makes it easy for you to not only have multiple health plans but also to make multiple claims as and when needed. Health insurance is a modern-day boon and you should make full use of it by getting adequate coverage and using it to keep yourself fit and healthy in every possible way.