claim from multiple health insurance plans

How to claim from Multiple Insurance Plans

Health insurance is a life protecting instrument that people like you and I purchase for saving our lives from uncertain situations shortly. A health insurance policy provides you cover and pays your hospital bills for any illness or unfortunate incident that may or may not occur later. It is like an umbrella to your life.

In times of emergency, an individual’s situation gets stressful, and the thought that you need to pay money for treatment out of your pockets, although you did not expect such a situation and be ready for it, adds to the stress. Health insurance plans allow you to feel a little relief as the program supports you in paying those expenses.

Is it possible to have more than one health insurance policy?

 Yes, it is possible to have more than one health insurance policy. It is usually advised to have more than one insurance policy, and it follows that the most important principle is not “putting all your eggs in one basket.” Having more than one policy will help you afford medical treatment even after the costs increase as the coverage you will receive will be sufficient.

Reasons why you shall have multiple insurances

One of the primary purposes of purchasing life insurance is if you have dependents or does not make sense for everyone.

  1. One of the benefits of having multiple/single health insurance plan is saving on taxes. Just like death, tax is also inevitable.
  1. Your financial situation and family member’s dependent on you also help determine the number and type of policies you need.
  1. If you purchase a money-back policy, you need to make sure that the pay-out being offered is equal to your monthly payment as the money shall suffice the minimum requirements.
  1. For receiving coverage to protect your family and yourself from uncertain situations.
  1. Insurance is also considered as an investment avenue and is relatively safe. It can act as an instrument that will help you repay debts (if any).installments

To understand if multiple claims are allowed, let’s know the maximum number of requests that you can file a claim within a year. 

You can file multiple claims in one year only up to the amount insured that is pre-decided coverage set by the insurance company. It means that if you claim for a particular illness, the maximum sum insured then, the insurance company will not accept any further claims as the sum insured has been exhausted.

Assuming that the sum insured by the insurance company gets exhausted within two-three claims filed by you, this means a further request can be made only if earlier you have renewed your insurance policy. In simple terms, a plan is renewed every year, or the premium is paid in instalments to continue the benefit of receiving coverage. When you as a policyholder abide by the payment payable on time, the insurance company gives you a bonus known as restoration benefit or refill benefit.

When the sum insured has been exhausted, the role of restoration comes into the picture. The restoration benefit directly refills the policy’s necessary sum and helps you feel relieved by doubling the sum earlier insured.

For example, X has an insurance policy of RS.8 lakhs, and he underwent a liver transplant, for which the hospitalization bill cost around six lakhs. The amount was claimed and reimbursed, respectively.

In the same year, X undergoes an accident and uses the remaining sum insured. Later, due to the liver transplant, the insured was facing few issues and needed to undergo an operation again and had the restoration benefit of RS.4 lakh. The insurance company will not grant any claim for the same health issue once also the same year.

To sum it up, multiple claims are allowed in a single year, but the issue shall not be repeated as insurance companies do not grant reimbursement for the same illness twice. In the case of multiple policies, the liability is shared in a specified proportion.

We can now understand that more than one claim for the same illness from the same insurance policy is not allowed. Still, if you have multiple insurances and cover one condition, a single procedure is not enough. You can use the other approaches to claim for the same illness. 

Filing claims under multiple insurances:

 You may purchase multiple insurance policies with the fear of falling short of coverage due to the rapid rise in medical equipment and treatment costs, which is very logical and future, foreseeing.

When a person falls ill and seeks medical treatment, in some cases, that one insurance plan does not suffice to pay for the entire hospitalization bill. In such cases, the insured can claim under the second insurance plan. If the insured has taken two policies from different companies, they need to be informed that the policyholder holds more than one procedure. 

If the person does not disclose the companies, then while filing a claim, the claim may be dismissed and rejected due to non-disclosure of material facts, which is a violation of the insurance contract. Before 2013, disclosing the information in case of a claim meant the expense will be equally divided among the insurance companies. This was popularly called the “Contribution Clause.”

Subsequently, in 2013, the Insurance Regulatory and Development Authority of India (IRDAI) declared that the contribution clause is eradicated. The policyholder can approach any one insurance company out of the multiple insurances he held to file a claim to receive a reimbursement and these insurance companies will internally adjust.

  • Process:

When an individual files a claim, the repayment can be done through cashless methods or the reimbursement model. The person can request the second insurance company only if the sum insured by the first policy is entirely exhausted.

  1. Illness

For example, you have a group insurance policy and two personal health insurance plans. Unexpectedly, your blood pressure level drops suddenly, and you are admitted to a hospital included in the hospital network under your insurance company.

  1. Under coverage –

First, you need to understand if the illness is given coverage under the insurance plan, if, yes, you can file a claim. As blood pressure is considered a pre-existing condition, the request will be valid if the insured has served a waiting period.

  1. Know the amount –

You must know the final claim amount, i.e., the hospitalization bill is considered the final amount. You will have to receive the bill’s receipt, and only after that, you can go ahead and file a claim. Let’s assume the account to be approximately eight lakhs.

  1. Type of policies owned –

In this example, you have a group insurance policy and two personal health policies. It is advisable for an individual to first claim out of the group health policy to help you earn a no claim bonus on your health insurance.

  • Group health insurance: Coverage of RS.3 lakhs. Cashless transactions are available.
  • X individual health insurance: Cover of Rs.4 lakhs. Cashless transactions are available.
  • Y individual health insurance: Cover Rs.3 lakhs. Co-pay 10%. Reimbursement route available.
  1. Choose –

In simple terms, choosing the group coverage will be logical. After that, X individual policy shall be selected to help you enjoy the benefit of cashless transactions and have no co-pay clause. The Y insurance policy will be the last option as the other two policies’ service is better than this one.

  1. First claim –

Raise the claim from the group health insurance policy, and in this case, you can enjoy the benefit of a cashless transaction. Once the claim is settled, you can go ahead and attach all the required documents along with the claim settlement summary to the second insurance company.

  1. Second claim –

Once sanctioned, the second claim can move forward and claim the balance bill from the insurance company. Here, the amount for filing a claim will be Rs.90,000 as the co-pay clause is applied. In this case, you have to attach the claim settlement summaries and discharge summary, lab reports, medicine bills, etc., while filing the claim.

Documents required for filing claims for reimbursement:

  • Discharge summary
  • Bills/receipts
  • Laboratory reports
  • X-rays
  • Medicine bills/prescriptions
  • Claim form (for filing the claim)
  • Claim settlement summary(s) (in case of multiple claims made)

FAQs: Claim From Multiple Health Insurance Plans

Is it possible to have more than one health insurance policy?

Yes, it is possible and very legal in India to have more than one insurance plan. It is usually advised to have extensive coverage in situations of any emergency. In most cases, a person includes themselves in a group plan offered by their employer and purchases a personal plan for back-up as the group plan does not have health coverage.
Having these two policies makes the holding of insurance plans considered multiple, but it is allowed to purchase more than these policies mentioned. The only thing affected here is that the tax benefit cannot be expanded and will remain the same, no matter how many policies you buy.

Is it true that hospitals in India reject most of the health insurance claims by patients?

No, it is not valid. There are many reasons for getting your claim rejected. To mention a few:

1. While purchasing a health insurance plan, the insurance company pre-decides the sum insured for your policy; this means beyond the sum insured, no claims will be entertained. If you file a claim beyond the pre-decided amount, it is most likely that your request will be denied.
2. A particular set of diseases are not under the coverage of your insurance plan if you claim for any one of those diseases, then the claim will be rejected.
3. Insurance policies have a non-disclosure agreement clause if you hide a particular illness from the insurance company and later file a claim for the same disease. It is a violation of the clause, thus leading to the rejection of your request.
4. There is a waiting period for most illnesses and if you file the claim before the waiting period is over then the claim is likely to be rejected.

A claim is accepted or denied only after logical reasoning and understanding the validity of the request. No insurance company rejects claims without having a strong reason. That is evident from the high claim settlement ratio of these companies. Also, even if your claim is rejected, you are entitled to re-submit your claim and even take it up with the IRDAI for redressal of your grievances.

How much time does the claim process of Health Insurance require?

Reimbursement of claims is done in cases where you are admitted to a hospital outside the network of hospitals included in your insurance plan. Once you file the claim, your claim's acceptance or rejection will be done after evaluating the claim documents. Most of the claims are settled within 15 to 30 days. In some cases, it takes longer if all the paperwork is not in place. If the request is filed of a vast amount, it takes time for the insurance company to scrutinize the documents and decide if the claim is valid or not.

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