Have more than one health cover? Here’s how you must file claims

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.

Check if the second insurer or TPA insists on certified copies of hospitalisation bill from the first insurer. If it does, then submit these certified copies of hospital bills and your first insurer’s settlement letter with another set of claim forms and present the balance claim’s application to the second 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.