Well being Insurance coverage: Tips on how to file medical health insurance claims from a number of insurance policies

Attributable to rising hospitalization bills and COVID-19, many people are opting to be coated by multiple medical health insurance coverage. These insurance policies might be characterised alongside the next dimensions.

Supply of Cowl Kind of Coverage Insurer
Particular person or Household Floater Base Similar
Group Well being Insurance coverage Tremendous Prime-Up a number of

Based on the IRDAI, the insured has the selection to assert from a number of insurance policies, even for a similar hospitalization occasion (please see Annexure for an excerpt from the IRDAI’s FAQ on this topic).

Nonetheless, the next ideas should be adopted in all circumstances:
* The identical expense is not going to be paid greater than as soon as.

* Settlement will likely be in line with the respective phrases and situations of every coverage

The above two ideas have totally different implications for cashless and reimbursement claims.

In the event you want cashless claims from two insurance policies, you’ll have to do it sequentially, ie, one cashless intimacy at a time, as a result of the identical expense shouldn’t be paid greater than as soon as. This brings up logistics challenges, if the insurer is totally different for the 2 insurance policies. Cashless approval from the second insurer will likely be obtained solely after the primary insurer approves cashless billing from the hospital. Given the elapsed instances concerned in cashless intimacy, hospital billing and cashless approvals, most hospitals require out of pocket cost by the insured to cowl interim prices. And as soon as the insured has paid money to the hospital, claims thereafter are largely settled on reimbursement foundation.

Due to this fact, in most sensible conditions, claims to the second insurer fall into the reimbursement class and do not stay cashless.

For reimbursement claims, the second insurer will normally settle for a duplicate of paperwork and declare settlement recommendation, duly licensed by the primary insurer topic to satisfaction of the second insurer, when the unique paperwork have been submitted to the primary insurer. Nonetheless, just like cashless claims and for a similar causes, reimbursement declare settlement for 2 insurance policies can even be sequential, ie, one after the opposite. Solely after the claims allowed underneath the primary coverage are settled, can the steadiness bills be claimed for the second coverage. Due to this fact, the elapsed time for full settlement between two insurers will normally be greater than twice the time for a single declare.

This sequential course of and associated paperwork are smoother when the insurance policies are from the identical insurer. The insurer then has info on claims for each insurance policies and the swap over doesn’t take time. Even for hospitals, the cashless approval course of is much less cumbersome, since they’re coping with just one insurer for the whole hospitalization occasion.

Annexure
The IRDAI (Insurance coverage Regulatory and Growth Authority of India) offers the next response in its FAQ listing concerning the norms for settlement of claims with a number of insurance policies:

If two or extra insurance policies are taken by an insured throughout a interval from a number of insurers to indemnify therapy prices, the policyholder shall have the precise to require a settlement of his/her declare by way of any of his/her insurance policies.

* In all such circumstances the insurer who has issued the chosen coverage shall be obliged to settle the declare so long as the declare is inside the limits of and in line with the phrases of the chosen coverage.

* A policyholder having a number of insurance policies shall even have the precise to favor claims from different coverage/insurance policies for the quantities disallowed underneath the sooner chosen coverage/insurance policies, even when the sum insured will not be exhausted. Then the insurer(s) shall settle the declare topic to the phrases and situations of the opposite coverage/insurance policies so chosen

* If the quantity to be claimed exceeds the sum insured underneath a single coverage after contemplating the deductibles or co-pay, the policyholder shall have the precise to decide on insurers from whom he/she needs to assert the steadiness quantity.

* The place an insured has insurance policies from multiple insurer to cowl the identical threat on indemnity foundation, the insured shall solely be indemnified the hospitalization prices in accordance with the phrases and situations of the chosen coverage.

Excerpts from T&C’s of Some Insurers


Star Well being Household Well being Optima:
ln case of a number of insurance policies taken by an insured individual throughout a interval from a number of insurers to indemnify therapy prices, the insured individual shall have the precise to require a settlement of his/her declare by way of any of his/her insurance policies. In all such circumstances the insurer chosen by the insured individual shall be chosen as to settle the declare as lengthy the declare is inside the limits of and in line with the phrases of the coverage

An insured individual having a number of insurance policies shall even have the precise to favor claims underneath this coverage for the quantities disallowed underneath every other coverage / insurance policies even when the sum insured will not be exhausted. Then the insurer shall independently settle the declare topic to the phrases and situations of this coverage

If the quantity to be claimed exceeds the sum insured underneath a single coverage, the insured individual shall have the precise to decide on an insurer from whom he/she needs to assert the steadiness quantity

The place an insured individual has insurance policies from multiple insurer to cowl the identical threat on indemnity foundation, the insured individual shall solely be indemnified the therapy prices in accordance with the phrases and situations of the chosen coverage

Niva Bupa (Well being Companion): ln case of a number of insurance policies taken by an insured individual throughout a interval from a number of insurers to indemnify therapy prices, the Insured Particular person shall have the precise to require a settlement of his/her declare by way of any of his/her insurance policies. ln all such circumstances the insurer chosen by the insured individual shall be as to settle the declare as lengthy the declare is inside the limits of and in line with the phrases of the chosen coverage.

Insured individuals having a number of insurance policies shall even have the precise to favor claims underneath this coverage for the quantities disallowed underneath every other coverage / insurance policies even when the sum Insured will not be exhausted. Then the insurer shall independently settle the declare topic to the phrases and situations of this coverage.

lf the quantity to be claimed exceeds the sum insured underneath a single coverage, the insured individual shall have the precise to decide on the insurer from whom he/she needs to assert the steadiness quantity.

The place an insured individual has insurance policies from multiple insurer to cowl the identical threat on indemnity foundation, the insured individual shall solely be indemnified the therapy prices in accordance with the phrases and situations of the chosen coverage.

Ergo Optima Safe: Within the occasion of a declare lodged underneath the coverage and the unique paperwork having been submitted to every other insurer, the corporate shall settle for the copy of the paperwork and declare settlement recommendation, duly licensed by the opposite insurer topic to satisfaction of the corporate.

(The author is Director, SANA Insurance coverage Brokers)