How to Claim for Health Insurance from Multiple Insurers

Last Updated: May 12, 2022 | 3,543 Views
Healthcare costs were significantly lower a decade ago. A health policy of Rs. 2 lakh back then could provide adequate coverage for a small family but today it wont be close to being sufficient for an individual. 

Galloping inflation in healthcare industry and changing life>

Multiple policies give rise to multiple queries regarding the claims process:

  • Should I claim with one company?
  • Should I split the claim amount among multiple insurance companies?
  • On which policy should I claim first?
  • Which bills would individual insurers require?
  • Do the insurers need to know about additional covers?
  • The above is by no means a comprehensive list of the questions that emerge, but they are all pertinent questions that come into play during claim season. So what should you do when the time comes to file claims?

Group Health Plans V/S Individual Health Plans

It is very important for each and every person to purchase an Individual Health Plan over and above the group plan provided by the organization.  Some of the common questions related to group health insurance plans are:
  • Who provides for your Health Care Benefits post retirement?
  • What happens to your plan if you quit you your Present Organization and move to an Organization without a Health Coverage?
  • Who will provide you with a High Cover Health Plan after you have conceived illnesses like Diabetes, Heart Ailment, etc.?
  • With Medical Inflation beating regular Inflation by over 5%, how can one suffice for the Medical Expenses without a Health Plan?
The debate can be unending but the most sensible thing to do is to compare health insurance plans policies for an Individual Health Plan before conceiving any ailment. You will be eligible for No Claim Bonus as well if you dont make any claims during the year. Also. on continous renewal the waiting period for specific illnesses will also be covered. 
Now, once you know which is the best health insurance policy, you can have an Individual Health Plan over and above the Group Plan. However, the classic question that arises is, 'Which one to claim from and when?' 
  • It is ofcourse advisable to exhaust the claim limit on your group insurance plan first, if you have one at your workplace. A Group Policy Claim is settled much smoothly than an Individual Health Insurance Claim.
  • A claim on your Individual Policy may lead to a loading charge on your renewable premium and you would not be eligible for the No Claim Bonus for that year.
  • Moreover, if your Individual Health Plan is a relatively new one i.e. within a couple of years then it may not cover pre-existing conditions and have a waiting period for a few standard hospitalizations and illnesses.
But make sure to inform all your insurers and third party administrators (TPAs) about your hospitalization. In case the group policy does not cover the entire costs of hospitalization, being upfront with your other insurance provider will facilitate the claims process.

When you have multiple personal policies
In the case, when you have two or more similar health insurance policies, the contribution clause comes into play. Under this clause, your multiple policies will contribute towards claims proportionate to their respective coverage levels. For example, if one policy offers Rs. 5 lakh coverage and the other offers Rs. 3 lakh coverage, them the first policy will pay 5/8th of the claim amount and the second will pay 3/8th of the claim amount.

On the other hand, you could buy multiple policies to distribute the risk. For instance, your base policy could be a regular health insurance plan while your second policy could cover a specific pre-existing disease that is excluded by the first plan. In this case, costs are distributed depending on the type of illness.

In case of different plans from the same insurer, work on retaining the same TPA. This will smooth out the claims process.

Things to do when filing multiple claims
As mentioned above, you need to keep all your insurers and TPAs in the loop during hospitalization and inform them that you have more than one health plan. In fact, health claim forms require the insured to furnish details about other policies as well. This is so that even if the insured claims from a single insurer, that insurer will follow-up with the other health insurers for their contributions towards the particular claim.

Note that if one of your policies is brand new and still within the waiting period, claims will be processed by your earlier policies. New policies have a waiting period of 2 to 4 years for certain illness such as like cataract, piles, etc. and also sometimes for Maternity and Pre Existing Illnesses. Hence, older health insurance plans come much handy to cover the same.

Remember that all your multiple insurers will require the original bills and documents at the time of making a claim. In that case, if the hospital is unwilling to provide you with duplicates, attested copies of the documents will suffice.

Things to keep in mind for Health Insurance Claim from multiple insurers:
  • Irrespective of whether you have a Group Health Insurance Plan or not, an Individual Health Plan is mandatory. It is important before you contract any serious illness so that the same is not excluded from your health policy.
  • If you have a Group Insurance Coverage, it makes most sense to claim from the group plan first because the claim settlement is much smoother and easier under a group health insurance plan
  • Contribution Clause comes into action as soon as Multiple Health Plans come into action and the claim is settled as per the percentile of coverage
  • Older policies should be used for claims before the newer ones so that the waiting periods for Pre-existing illnesses, maternity, etc. are over before the same is claimed from the new health insurance plans as well.

Points to Ponder:
Thus, if you feel, I am pushing you towards opting an Individual Health Insurance Plans, then you are mistaken. In fact I would advise each and every bread earner of the family to:
  • Think of their family’s medical expenses in tune to the ever-rising medical inflation which has been inflated further due to the new industry of medical tourism and changing life>
  • Think of a Critical Illness Plan over and above a Reimbursement Health Plan such that a lumpsum money would be payable to the family on diagnosis of any of the specified Critical Illnesses
  • Consider a Top Up Health Plan or a Super Top Up Health Plan in case you wish to enhance the medical coverage of your family

Manoj Aswani
Manoj is the co-founder and COO of MyInsuranceClub. He has experience in Financial Services, Internet, Insurance and Outsourcing business. He has done his Post Graduation from XLRI, Jamshedpur.