Taking Cover. Multiple health policies, 2 ways to claim

Joe, who initially bought a health policy for ₹5 lakh, thought it would be insufficient. In his mid-thirties, Joe decided to buy another health cover for ₹5 lakh from another insurer. Whether gut feeling or rational sense prevailed, he happened to incur medical expense of over ₹8 lakh. His bills are covered under the health policies, but how should he go about it?

Earlier, it was necessary for the policyholder to declare, if he/she has another health cover. Also, the claims will be settled by the insurers on pro-rata basis, that is, settlement of claims proportionately based on the sum insured of each policies.

But post 2012 regulations, these were not mandatory and it is up to the policyholders to decide how he/she wants to claim.

Like Joe, it is possible that you may have more than one health insurance policy to cover medical expenses.

In such cases, at the time of claim, you can decide which insurer and policy you want to go with. But if your medical expenses exceed the limit under one policy, here’s how to claim on multiple health policies at the same time.

There are two ways to go about the claim. One is reimbursement and the other is cashless method (where the bills are settled directly to the hospitals).

Though most of the insurance covers are cashless today, there are situations when companies may not be able to provide this service.

This could happen when a hospital is not networked under the insurance service provider or a certain expenses such as OPD (out-patient department) cannot be made cashless (as is the case with some health insurance policies). In such cases, medical expenses have to go from your pocket which can later be reimbursed from the insurer.

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Be careful with bills

If you want to use two health policies to cover your cost, you should invoke one claim at a time. “It is always one claim at a time, because one insurer will require definite proof of the amount settled by the other insurer to know his exact liability” according to Vaidyanathan Ramani, Head Product and Innovation, Policybazaar.com

For instance, if a policyholder has ₹5 lakh cover from insurer X and another cover from Y for ₹5 lakh and the medical bill comes to ₹8 lakh. First, the policyholder has to notify the first insurer or primary insurer and invoke a claim. Once this claim is settled, he can contact the other insurance company to cover the rest of the expenses. For this, the policyholder needs to submit photocopies of all the bills, attested by the first insurer, along with claim settlement report received from the same insurer.

“It is necessary for the policyholder to get the documents attested from the first insurer as the latter retains the original documents. To avail reimbursement with the other insurer, the customer will have to submit these documents to the second insurer,” according to Prasun Sikdar, MD and CEO, Cigna TTK Health Insurance.

Cashless mode

Usually, most of your in-hospitalisation medical expenses are covered by the insurance companies taking the cashless route. These days, some of the insurers provide cashless cover for OPD (out-patient department) too. This is easy if all your expenses are covered under one health policy. If not, the policyholders should intimate all the insurance companies from whom claims are to be invoked.

Generally, policyholders follow the cashless route with one of the insurers and get the rest of the expenses reimbursed from the other insurer. Photocopies of the bills should be collected from the first company to make the claim with the other insurer.

According to Vaidyanathan Ramani of Policybazaar.com, invoking cashless claims from two insurers may appear difficult, but given the advancements in medical industry, hospitals are well-versed with the procedures. “The minute you tell them you have two health policies, they will guide you,” he says.

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