How to claim from multiple health plans

Since the outbreak of pandemic last year, many individuals have considered purchasing a health policy for self as well as for family. While having one health policy with sufficient cover based on individual or family needs is adequate, many end up having multiple health policies. Usually, as policyholder you will have a group cover from your employer and an individual health cover (as the group cover offered may not be sufficient) or in some cases, it can be two separate policies from different insurers. At the time of claim, if you are among those individuals with two or more health policies, here is how you should go about the claim.

One by one

Almost all insurers have wide hospitals under their network to make cashless facility hassle free for the policyholders. Barring a few scenarios, including certain treatment or diseases not covered by the policy and treatment taken in a non-network hospital, your health policy should be able to meet the hospitalisation expenses for you (cashless). But irrespective of the number of policies, you can make one claim at a time only, be it cashless or reimbursement. This is because insurers require policyholders to submit the original bills while filing a claim.

Suppose you have two health policies and you want to have cashless under both, then you must indicate to the hospital or the TPA about this. Many insurance experts suggest that it is better to exhaust the sum insured of one policy before claiming from another. Priya Deshmukh Gilbile, Chief Operating Officer, ManipalCigna Health Insurance, says “In case of a cashless claim, with the same TPA, the co-ordination for two or more policies become easier. Even if the TPAs are different for the policies held by policyholder, cashless can be done. The approval letter from the first insurer has to be submitted to the second insurer for the remaining claim amount”

However, there could be practical difficulties when it comes to cashless claims from multiple insurers. According to Indraneel Chetterjee, Co-Founder, RenewBuy “While cashless facility from multiple policies is doable by TPA/insurer, there could be a little struggle in terms of co-ordination between the TPA, insurer and the hospital due to incremental operational work.”

Hence you can also plan your claim (medical expenses) part cashless and part reimbursement. Suppose you have two policies of ₹5 lakh each and your expenses work out to ₹6 lakh. In this scenario, up to ₹5 lakh, the hospital/TPA will co-ordinate with the insurer. For the balance amount of ₹1 lakh, you as policyholder need to submit the bills given by the hospital along with discharge summary (which will mention the claim covered) to the other insurer for reimbursement. It could help you have a smooth claim procedure and avoid unnecessary delay at the time of discharge or while starting a treatment.

Keep in mind

While having multiple health policies has its advantages, there are a few points to keep in mind, when making a claim, in order to reap the maximum benefits.

One, you should go for the policy which has minimum or no co-payment (where policyholder agrees to pay a certain percentage of medical expenses and the balance paid by the insurer) or sub-limits (refers to the limits for a certain medical treatments or diseases in a policy) clauses. This is so that the difference between medical bills and claim amount (settled by insurer) is low. If you have to choose between a group cover and an individual health cover, then go for group health insurance first. This is because, the benefits of no-claim bonus remains intact.

Two, it is important to disclose to each insurer about the multiple policies you hold, if specifically asked in the proposal form at the time of purchase of health policy. The non-disclosure of the other policies may affect at the time of claim as it is a breach of (insurance) contract and insurer have the right to reject or not settle your claim. However, not many insurers ask for this disclosure these days.

Lastly, while there is no cap on the number of health policies that you can buy, the premium amount you shell out for every renewal could be high for all the policies. Amit Chhabra, Head Health Insurance, Policybazaar.com says “For policyholders it is better to have a base policy and then have top-up plans from the same insurer, as it will work out to be affordable and for easier claim, instead of having separate policies from different insurer. ”