Health Insurance: How to File Health Insurance Claims from Multiple Policies

Due to rising hospital costs and COVID-19, many of us choose to be covered by multiple health insurance policies. These policies can be characterized according to the following dimensions.
Source of coverage Policy type Insurer
Individual or Family Float Base Same
Group health insurance super recharge Several

According to IRDAI, the insured has the choice of claiming one or more policies, even for the same hospitalization event (see appendix for an extract from the IRDAI FAQ on this subject).

However, the following principles must be observed in all cases:
* The same expense will not be paid more than once.

* Settlement will be made according to the respective terms and conditions of each policy

The above two principles have different implications for cashless and refund requests.

If you need cashless claims of two policies, you will have to do it sequentially, i.e. one cashless notification at a time, since the same expense should not be paid more than once. This raises logistical challenges, if the insurer is different for the two policies. The second insurer’s cashless approval will only be received after the first insurer approves the hospital’s cashless billing. Considering the time elapsed for cashless notice, hospital billing and cashless approvals, most hospitals require direct payment from the insured to cover interim charges. And once the insured has paid cash to the hospital, subsequent claims are usually settled on a reimbursement basis.

Therefore, in most practical situations, claims with the second insurer fall into the category of reimbursements and do not go cashless.

For refund requests, the second insurer will generally accept a copy of the documents and notices of claims, duly certified by the first insurer subject to the satisfaction of the second insurer, when the original documents have been delivered to the first insurer. However, like cashless claims and for the same reasons, settlement of claims for two policies will also be sequential, i.e. one after the other. It is only after the claims allowed under the first policy have been settled that the remaining expenses can be claimed for the second policy. Therefore, the elapsed time for a full settlement between two insurers will typically be more than twice that of a single claim.

This sequential process and related paperwork is smoother when the policies are from the same insurer. The insurer then has information on the claims for both policies and the changeover does not take long. Even for hospitals, the cashless approval process is less cumbersome, since they only deal with one insurer for the entire hospitalization event.

Annex
IRDAI (Insurance Regulatory and Development Authority of India) provides the following answer in its list of FAQs on claims standards with multiple policies:

If two or more policies are taken out by an insured during a period with one or more insurers to compensate the treatment costs, the policyholder has the right to demand the settlement of his claim under the one of his fonts.

* In all such cases, the insurer who issued the chosen policy is liable to settle the claim as long as the claim is within the limits and under the terms of the chosen policy.

* A policyholder with multiple policies will also be entitled to prefer claims from other policies for amounts disallowed under the policy or policies previously chosen, even if the sum insured is not exhausted. Thereafter, the insurer or insurers will settle the claim subject to the terms and conditions of the other policy or policies so chosen.

* If the amount to be claimed exceeds the sum insured under a single policy after taking into account deductibles or copayments, the policyholder will have the right to choose the insurers from whom he wishes to claim the balance.

* When an insured has policies with several insurers to cover the same risk on an indemnity basis, the insured will only be compensated for hospitalization costs in accordance with the terms and conditions of the chosen policy.

Extracts from the T&Cs of certain insurers


Star Health Family Health Optima:
In the event of several policies taken out by an insured during a period with one or more insurers to compensate for treatment costs, the insured has the right to demand the settlement of his claim under one of his policies. . In all these cases, the insurer chosen by the insured is required to settle the loss as long as the loss is within the limits and according to the terms of the chosen policy.

An Insured Person with more than one Policy shall also be entitled to prioritize claims under that Policy for amounts disallowed under any other policy/policies even if the Sum Insured is not exhausted. Then the insurer will independently settle the claim subject to the terms and conditions of this policy

If the amount to be claimed exceeds the sum insured under a single policy, the insured has the right to choose the insurer from whom he wishes to claim the balance.

When an insured person has taken out policies with several insurers to cover the same risk as compensation, the insured person will only be compensated for treatment costs in accordance with the terms and conditions of the chosen policy.

Niva Bupa (health companion): In the event of several policies taken out by an Insured during a period with one or more insurers to compensate for the treatment costs, the Insured will have the right to demand the settlement of his claim under one of his policies. . In all these cases, the insurer chosen by the insured is required to settle the loss insofar as it is within the limits and according to the terms of the chosen policy.

Insured persons with more than one policy are also entitled to prioritize claims under this policy for amounts denied under any other policy/policy even if the sum insured is not exhausted. Thereafter, the insurer will independently settle the claim subject to the terms and conditions of this policy.

If the amount to be claimed exceeds the sum insured under a single policy, the insured has the right to choose the insurer from whom he wishes to claim the balance.

Where an insured has policies with more than one insurer to cover the same indemnity risk, the insured will only be compensated for processing costs in accordance with the terms and conditions of the chosen policy.

Ergo Optima Secure: In the event of a claim under the policy and delivery of the original documents to any other insurer, the company will accept the copy of the documents and the notice of settlement of the claim, duly certified by the other insurer subject to the satisfaction of the company.

(The author is Director, SANA Insurance Brokers)

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