Have
more than one health cover? Here’s how you must file claims
You can claim hospital expenses through multiple insurance
policies if individual covers, on their own, are inadequate
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Many victims of COVID-19 have discovered the
hard way that their insurance covers were inadequate to cover the cost of
treatment. With exorbitant hospitalisation bills of over Rs 18 lakh being
charged in some cases, even those with health insurance policies have had to
shell out large sums from their own pockets. But some policyholders have a
peculiar dilemma. They have sufficient insurance cover, but it is spread over
multiple health policies. Is it still possible to get complete reimbursement
for your hospital bills in such cases?
Deciding which policy you must claim from
Let’s say you have an office-provided insurance cover. Say, your
employer’s health cover, which promises to reimburse your hospital bills, has a
sum-insured of Rs 3 lakh. At the same time, you also have your own, personal,
health cover – again, reimbursement-based – of Rs 3 lakh. Say, your
hospitalisation bill is Rs 2 lakh. In this case, you can choose either of the
two policies for the entire claim settlement.
A small tip for you: If you have to choose between a group (your
company provided cover) and individual policy for claim settlement, exhaust
your office cover first, as claim settlements tend to be smoother with group
policies.
On the other hand, if your hospitalisation bill amounts to, say,
Rs 4 lakh, you can claim Rs 3 lakh under your group cover and the balance Rs 1
lakh under you own policy. If one insurer does not pay for certain expenses –
for example, amount over and above the room rent sub-limit in the policy – you
can claim this amount from the other insurer. However, you cannot claim Rs 3
lakh each under both policies. The idea is that health insurance policies are
not meant to be profited from; they just reimburse your actual hospital
expenses.
The claim process insurers follow
You can claim your hospital bills either directly through your
insurer or via a third-party administrator (TPA) that your insurer has
appointed. Make sure you intimate all your insurers when you get hospitalised.
You have to let them know by the time you are hospitalised that you would be
filing your claims later, after you get discharged.
Insurance companies always ask for original hospital bills. The question is: how can you submit the same set of original bills to two insurance companies? Submit the claim forms and the original set of documents to whichever insurer you decide to go to first. Request the insurer to give you certified copies of hospital bills. Then, along with your claim amount, the insurer will also give you a settlement letter. This letter, or voucher, will contain details of the amount settled by the first insurer.
If both your policies are with the same insurer or the TPA, the
process will be simpler.
“Hospitals generally do not prefer to deal with
more than one insurer. So, usually, cashless settlement under both policies is
difficult. Policyholders will have to later file reimbursement claim (for the
balance amount) under the other insurer’s policy,” says Bhaskar Nerurkar,
Head-Health Claims, Bajaj Allianz General Insurance.
Similar is the case even if you have a regular base policy and a top-up cover from the same insurer, though there could be exceptions. “On a case-to-case basis, however, we have managed to provide cashless facilities through network hospitals when the base policy is with another insurer. It depends on relationships with network hospitals and insurers,” he adds. Else, you will have to file reimbursement claims with the insurer that offered you the top-up, after furnishing the bills and the base insurer’s settlement voucher.
Making claims from reimbursement and benefit policies
Benefit-based or fixed-benefit policies pay out the entire
sum-insured upon diagnosis of ailments specified in the policy contract.
Typically, these are critical illness policies, but the newest fixed benefit
entrant in the market – Corona Kavach standard COVID-19 policy – covers the
hospitalisation expenses of the pandemic as well as co-morbidities (that is,
pre-existing illnesses) arising out of it. These policies can complement
regular, reimbursement policies as you can file claims under both covers.
For example, let’s say a policyholder has a
reimbursement cover of Rs 3 lakh and a fixed-benefit policy of Rs 3 lakh. She
undergoes a cancer surgery to remove a malignant tumour, which costs her Rs 3
lakh. Now, she can claim Rs 3 lakh from her reimbursement policy so that her
treatment expenses are taken care of. She can also claim this amount under the
fixed-benefit policy. It will come in handy for managing post-surgical recovery
expenses, loss of income and so on. The claim process in case of fixed-benefit
policies is relatively simpler – you simply need to submit photocopies of
treatment bills as proof of contracting the illness and the sum insured will be
paid to you.
https://www.moneycontrol.com/news/business/personal-finance/have-more-than-one-health-cover-heres-how-you-must-file-claims-5607411.html
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