The cost of quality healthcare has risen sharply. By purchasing a health insurance plan, you can ensure quality healthcare for your family. As your family grows or as the healthcare costs rise, you may have to increase your health insurance coverage. You can either increase health cover/Sum Insured in the existing plan or purchase another health insurance plan. Enhancement of Sum Insured in the existing health plan is a pretty straight forward process. You request the insurer for enhancement. It will arrange a few medical tests to assess its risk for the enhanced cover and issue the plan for an additional premium. There will no difference in the claims process. However, if you opt for a second plan, the claims process can get a bit cumbersome.
In this post, I shall try to answers some of the common questions that you might have if you have multiple health plans.
How does IRDA, insurance regulator take view of the two separate plans? At the time of claim, do you have to make claim with both the insurers? Can the insurance company insist on sharing the claim amount with other insurers? What are your rights? How much is the insurance company’s discretion? What is the regulator view on multiple policies? Can you claim more than the hospitalization expenses incurred? Can you profit from the hospitalization by claiming full amounts from the two or more insurers?
There are two kinds of health insurance plans. Indemnity plans and Defined Benefit (or fixed benefit) Plans. I will first discuss the difference between the two kinds of health plans. The reason is that the treatment of multiple health insurance policies depends on the type of health insurance plan.
Indemnity Plans and Defined Benefit Plans
As the name suggests, under an indemnity plan, you are indemnified for the expenses incurred on hospitalization. Under Indemnity plans, you are reimbursed hospitalization expenses or provided cashless treatment subject to a maximum of Sum Insured per policy year.
On the other hand, in case of defined benefit plans, there is no relation to the actual treatment expenses incurred. On occurrence of a covered/insured event (diagnosis of a critical illness), the insurance company pays you the cover amount (for the illness). Critical Illness Plans and Personal Accident Plans are defined benefit plans where the benefit is not linked to medical treatment expenses.
No matter how many indemnity health insurance plans you purchase, you cannot claim more than the cost of treatment from all the plans combined. For instance, you have a hospitalization bill of Rs 2 lacs. If you claim Rs 1.5 lacs under your first plan, you cannot claim more than Rs 50,000 from the remaining health insurance indemnity plans.
Please understand the above condition does not apply to defined benefit plans. For instance, you have an indemnity health insurance plan of 5 lacs and a critical illness plan of Rs 10 lacs. Now suppose you get diagnosed with cancer and the treatment costs you Rs 3 lacs. Indemnity plan will pay you (or the hospital in case of cashless hospitalization) Rs 3 lacs. On the other hand, your critical illness plan will pay you Rs 10 lacs. It does not even matter if you go through any treatment or not. You will be paid the amount on cancer diagnosis. Even though the treatment cost was only Rs 3 lacs, you have been paid Rs 13 lacs by the insurance companies. If you had two indemnity plans (instead of one indemnity and one critical illness plan), you would have been paid a maximum of Rs 3 lacs.
This does not mean you should purchase critical illness plans. There are a number of caveats. Please go through this post for more on critical illness plans and whether you should purchase such plans.
What is Contribution Clause?
Following is the standard definition of Contribution as per IRDA, the insurance regulator.
Contribution means essentially the right of an insurer to call upon other insurers liable to the same insured to share the cost of an indemnity claim on a rateable proportion of Sum Insured.
So, essentially, if you have multiple plans, an insurer can ask other insurers to share the claim cost. Let’s look at the extract from IRDA regulations on multiple policies.
Extract on multiple policies from IRDA Health Insurance Regulations, 2013
- If two or more policies are taken by an insured during a period from one or more insurers, the contribution clause shall not be applicable where the cover / benefit offered:
- is fixed in nature;
- does not have any relation to the treatment costs;
- In case of multiple policies which provide fixed benefits, on the occurrence of the insured event in accordance with the terms and conditions of the policies, the insurer shall make the claim payments independent of payments received under other similar policies.
- If two or more policies are taken by an insured during a period from one or more insurers to indemnify treatment costs, the insurer shall not apply the contribution clause, but the policyholder shall have the right to require a settlement of his claim in terms of any of his policies
a. In all such cases the insurer who has issued the chosen policy shall be obliged to settle the claim without insisting on the contribution clause as long as the claim is within the limits of and according to the terms of the chosen policy
b. If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the policyholder shall have the right to choose insurers by whom the claim to be settled. In such cases, the insurer may settle the claim with contribution clause.
c. Except in benefit policies, in cases where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with terms and conditions of the policy
I checked the policy wordings of a few plans from Apollo Munich and Max Bupa. Though the language used was slightly different, the message conveyed was the same. Insurer can invoke the contribution clause only if the plan is an indemnity plan and the claim amount is greater than the Sum Insured. Moreover, the contribution clause can be invoked only on an indemnity plan (and not defined benefit plan)
From the IRDA regulations, we can see that the insurer cannot always exercise this right. This means Contribution clause is not always applicable. Let’s consider various scenarios.
If you have purchased two Critical Illness Plans
As per IRDA, contribution clause shall not be applicable if the insurance plan benefit is fixed in nature or does not have any relation to treatment costs.
Hence, if you have purchased five critical insurance plans (there is no reason why you should purchase five) with Sum Insured of Rs 5 lacs and you get diagnosed with cancer, all the five policies will pay you Rs 5 lacs each. You will get Rs 25 lacs in total. This is because a Critical Illness Plan is a fixed benefit plan and contribution clause is not applicable.
Though I prefer using the keyword Sum Assured in case of defined benefit plans, I will use Sum Insured to avoid confusion.
If you have purchased one Indemnity and one Critical Illness plan
Contribution clause is not applicable for critical illness plans. If you have indemnity plan of Rs 5 lacs and critical illness plan of Rs 10 lacs and get hospitalized for cancer treatment. The treatment costs Rs 3 lacs.
Indemnity plan will pay Rs 3 lacs and critical illness plan will pay Rs 10 lacs. You will get Rs 13 lacs in total.
If you have purchased two Indemnity plans
This is where all the complications arise and the insurer has some discretion. Let’s assume you have two plans of Rs 5 lacs each from Apollo Munich and Max Bupa.
If the claim amount is Rs 3 lacs (less than Sum Insured)
You have the right to choose policy under which you want to claim. As long as the insurance claim amount is less than the Sum Insured, the insurer cannot insist on contribution clause. So, if you choose Apollo Munich to settle the claim, it will have to pay the entire Rs 3 lacs.
If the claim amount is Rs 6 lacs (more than Sum Insured)
In this case, the claim amount exceeds the Sum Insured under a single policy after considering the deductibles or co-pay. You still have the right to choose insurer to settle the claim. However, in this case, insurer CAN settle the claim with contribution clause. So, if you ask Apollo Munich to settle the claim, it can settle Rs 3 lacs and ask you to settle the remaining claim with Max Bupa (or settle with Max Bupa internally).
In this case, it is insurance company’s discretion to invoke the contribution clause. However, it may still choose not to invoke the clause. I talked to customer care teams of Max Bupa and Apollo Munich. From their responses, it appeared that they don’t invoke Contribution Clause too often. When I discussed exactly the same scenario with Max Bupa team, they told that they will settle Rs 5 lacs and I can claim the remaining Rs 1 lac from Apollo Munich.
You cannot profit from multiple indemnity policies
Even if you have two indemnity plans, the payout from such insurance companies combined cannot exceed total hospitalization costs. Hence, if you run up a hospital bill of Rs 3 lacs, the maximum payment from all the indemnity policies combined cannot exceed Rs 3 lacs.
Does purchase of multiple indemnity plans make sense?
We have discussed the IRDA regulations about making claims and the invocation of contribution clause. However, we are yet to discuss if you should purchase multiple health plans. Most people who want to purchase multiple plans had some grievance against their existing insurer or found the premium too high. Some of them thought if one of the insurers rejected the claim, they had chance with another insurer. Let’s discuss some of these issues.
You can port your existing health plan to another insurer
If you are unsatisfied with your existing health insurance plan, you can port your plan to another insurance company. The reason for dissatisfaction could be many including but not limited to high premium or scope of coverage offered. When you port your policy to other insurer, the waiting periods already serviced shall be deducted from the waiting period for the new plan. For instance, if you have already serviced waiting period of 2 years in an existing plan, your waiting period with the new insurer will be reduced by 2 years. So, if the new insurance plan has waiting period of 3 years, you will have to serve just one more year since you have already served two years in the old plan. This is as per IRDA guidelines. The insurance company has no discretion in this matter.
So, if you are not happy with your existing policy, you can shift to another insurer altogether rather than complimenting your existing cover with a new cover.
If one insurance company rejects the claim, the other company will honor it
A number of people purchase multiple health insurance plans to hedge the rejection risk i.e. they think if one insurer rejects their claim, they will be able to claim under the other policy. For this, you need to understand why and how insurance companies reject claims.
The insurer would want to prove that you didn’t make adequate medical disclosures at the time of purchase. If you have made adequate disclosures, it will find it difficult to prove that.
A number of rejections also happen because the policy holders have not understood the terms and conditions well. The insurance company may reject the claim if a certain procedure is not covered or there are sub-limits.
For instance, if the policy covers cataract treatment for only up to Rs 25,000 and you produce a bill of Rs 50,000 for cataract procedure, the insurance company will pay only Rs 25,000. And the insurance company is right in doing so. Caps on room rent can also throw up surprises at the time of claims.
So, do read the policy document carefully to understand the scope of coverage. This will save you hassles at the time of claims.
Don’t purchase multiple plans to hedge this risk. You just need to read the policy document well.
Marginal cost of health insurance keeps going down as you increased Sum Insured
Let’s consider the premium of family floater plans (for a couple, 30 years, 30 years) for Max Bupa HeartBeat Gold and Apollo Munich Optima Restore.
You can see that the amount that you pay for increasing sum insured from Rs 5 lacs to Rs 10 lacs is only Rs 3,439 in case of Apollo Munich and Rs 5,840 in case of Max Bupa.
This is because as you increase the cover, the likelihood of the insurer paying the entire amount as claim decreases. You are more likely to make a claim of Rs 5 lacs than a claim of Rs 10 lacs during a policy year.
Alternatively, if you had gone for two separate plans from Max Bupa and Apollo Munich of Rs 5 lacs each, you would have paid Rs 27,228. This is more than Rs 10 lacs plans from either Apollo Munich or Max Bupa.
You are likely to end up paying more premium if you purchase multiple small policies rather than a single large one.
Multiple plans may make sense in specific situations
In the previous sections, I have made the case against purchasing multiple plans. However, under certain specific situations more than one policy may make sense.
Let’s consider an example. Mr. Sharma has covered self, his wife and two children under a family floater plan of Rs 5 lacs. He wants to increase the cover to Rs 15 lacs. However, since the inception of his first plan, he has developed a heart condition. His current health insurer is loading the premium heavily (for the enhanced portion) to take care of increased risk.
In this case, Mr. Sharma can opt for a separate family floater for the other family members (his wife and children and exclude himself) and keep the existing cover for himself. For more on whether to go for family floater or an individual health insurance plan, please go through this post. Alternatively, Mr. Sharma can opt for a super top up health insurance plan. I will discuss top up and super top plans in a separate post.
You can argue that in case you have multiple plans and happen to claim under one of the plans, your no-claim bonus (or benefits) in the other plans will remain intact. However, I wouldn’t give too much weight to this argument.
Where to claim first?
A number of employers in the organized sector offer group health cover to their employees. Hence, it is not very uncommon to see people with multiple health covers i.e. one private (or personal) cover and one employer group health cover. Though I have discussed the pros and cons of multiple private plans in this post, I will consider a case you have group cover from employer and a private (personal) health cover. Similar logic will apply when you have two private indemnity plans (or individual plans).
If you have group health insurance and private health insurance both, use the group cover first. If there is no further hospitalization claim, your no-claim bonus will remain intact.
There is one scenario where you may keep your group cover intact and exhaust your private cover. In case when waiting period for pre-existing illnesses is not over in your private (individual) health insurance plan, you may be better off claiming under the private health plan.
For instance, you have to undergo a treatment for illness A and you can claim the amount under any of the two policies (group plan and private plan). There is another illness B for which the waiting period expires in another two years in your private health plan. There is no such restriction in your group plan. In such a case, you may be better off making a claim for illness A under your private health plan.
Consider a scenario where you make the claim under employer plan (for illness A) and it gets exhausted. Subsequently, during the same policy year, you have to get treatment for illness B. Employer health plan is already exhausted and private health plan does not cover the illness yet. In that case, you will have to pay from your pocket.
Basic rule: If any waiting period is pending, claim under the private health insurance plan first. After the waiting period is over, claim under the employer group plan first.
Follow the similar logic in case you have two private health plans. Claim first from the plan where waiting periods are pending.
Procedure to Claim under two policies
Suppose you have health insurance from Company X and Y.
First of all, inform both the insurers at the time of hospitalization.
In case you go for Reimbursement
- Collect all the original documents from the hospital at the time of discharge. The list of documents will include original bills, consultation papers, investigation reports etc. Take attested copies of these documents for the second insurer.
- Fill up the claim form and submit to X. Submit original bills with X. Disclose your insurance arrangement with Y in the claim form.
- Company X will settle part claim and issue a claim settlement letter.
- File for claim with insurer Y with the attested copies of the documents and claim settlement letter from company X.
- Company Y will settle the claim.
In case you go for Cashless treatment
Under cashless treatment, insurer X will settle the bill directly with the hospital. You can settle the process with the company Y through the steps mentioned in the previous section.
Thinks to keep in mind
- When you purchase a policy, disclose to the new insurers about your existing health insurance policy details. Non-disclosure of such information can be construed as misrepresentation. Insurers need to be aware of your existing health covers so that they can invoke the contribution clause if required. The IRDA guidelines are extremely customer-friendly. There is no need for you to worry. Be Honest.
- Inform both the insurers at the time of hospitalization.
PersonalFinancePlan Take
For most people, there is no need to have two different private health insurance plans. Purchase a plan that meets all your insurance requirements/expectations and that should be it. Go for a sufficient cover.
If you want to increase the Sum Insured, you can increase coverage under the same plan. You do not need to purchase a fresh plan for higher coverage.
If you are unhappy with existing insurer, you can port your plan to another insurer while retaining the continuity benefits.
Do not think that if one insurer rejects the claim, the other insurance company will honor it.
The premium for two plans with small covers will be higher than a single plan with large cover. Therefore, multiple plans do not make any economical sense either.
Add to it the hassles at the time of making claims. You will have to manage two claims. Double trouble. You can go cashless with just one policy. With the other, you will have to go for reimbursement.
In most cases, a single large health insurance cover will be better than multiple small health covers. However, in special situations (as in one of the examples discussed above), you might be forced or may find it beneficial to hold multiple health plans. So, there can be merit in purchasing multiple plans in specific cases.
If you choose to go with multiple plans, disclose details of your existing plans at the time of purchase of new plan. Similarly, at the time of making claims, disclose all you health insurance arrangements.
And yes, know your rights. Your health insurer can insist on contribution clause only in case of indemnity plans and only if the claim amount is greater than the Sum Insured.
Image Credit: The original image and information about usage rights can be downloaded from Flickr/401(K)Calculator
Deepesh is a SEBI registered Investment Adviser and Founder, PersonalFinancePlan.in
107 thoughts on “Claiming from Multiple Health Insurance Plans”
Hello Deepesh
I have employee cover of 3 lacs which as you might be aware is basic one with room rent cap etc ,i was planning to go for super top policy(10lacs) with LT&T medisure but i have certain Questions .My group policy is from national insurance and it covers me & my spouse .
1)How difficult is claim process as both companies being different and again entire process of getting 2 set of documents sounds tedious ? Or is it better to take top up from same parent insurer with whom you have base policy?
2)With not much casheless hospitals around paying from pocket and then reimbursing also doesn’t sound promising .
3)Also i was looking at Quotes from one of known websites and they inform me that if i take policy via their website they would assign service relationship manager who would take care during claim time? are these kinda of services worth or do u suggest to take policy directly through company ?
Hi,
I have replied to your query on e-mail. Am copying the answer here.
Room-rent limits can give shocks at the time of claim. There is a post on my website on room rent limits . Please go through the post. You might find it helpful. Please find the point-wise reply below.
1. Claiming from two policies will not be too easy. Nobody wants to part with money. Insurance companies are no different. You can go cashless with just one of the plans. For the second, you will have to get reimbursement. Do not go by what insurance companies say. They will promise the world when they are selling. Just because of the inherent structure of the super top up plans, these are likely to be reimbursement plans. I personally feel if you have regular and super top up plan from the same insurer, then the reimbursement process should be a bit simpler. Can’t say for sure though.
2. Even in regular health plans, not everything is covered by insurance policies. For instance, cost of towels and many other smaller things are not covered by insurance plans. Hence, be prepared for at least some payout from your pocket in case of hospitalization. You play the card you are dealt. If there are not many cashless hospitals around, you will have to go for reimbursement route. Or you can take cashless treatment at nearby large city.
3. Which site were you looking at? See, the role of intermediaries during the claims process is questionable. If the premium paid is same (I doubt it will be), you can go through them. Would suggest you purchase directly through company. You will save on money. Get clarity about the claim process from the company itself.
4. No recommendations on super top up policy. However, would suggest buy a policy that complements your employer plan. Would rather suggest you buy a regular top up plan of Rs 5 lacs for your family (rather than super top up plan of Rs 10 lacs). You have to decide on the affordability front. With room rent limit on your employer cover, you might to shell out a good amount from your pocket in case you get hospitalized. Employer covers have other restrictions too on caps on treatment cost etc. Take a call accordingly.
I am working on a post on top up and super top up plans. Should be able to post it by this month end. Hopefully, the post will have more precise inputs.
Hi deepesh,
I have the following query :
I hqd claimed an amount of Rs.90125 for the patient Neeta Mehta under a corporate group inssurance policy from National Insurance Co. Ltd. (TPA – Medi Assist India TPA Pvt Ltd) for hospitalization. The amount that was approved by National Insurance Co. Ltd. under the corporate policy was Rs 62781. ( i.e.70℅ and balance 30℅ shall be paid by the employee as per the corporate policy). For balance Rs.27344 , we have claimed under individual policy of New India Insurance Company which got rejected.
Can you please telle if I am entitled to receive Rs 27344 from New India insurance?
The reply I got from New India insurance company for rejecting the claim is this :
As per clause 5.6 of the Mediclaim 2007 policy as per IRDA guidelines, our contribution clause reads as follows :
CONTRIBUTION: If two or more policies are taken by the Insured Person during a period from one or more insurers to indemnify treatment costs, the Company shall not apply the contribution clause, but the Insured Person shall have the right to require a settlement of his/her claim in terms of any of his policies.
1. In all such cases the Company shall be obliged to settle the claim without insisting on the contribution clause as long as the claim is within the limits of and according to the terms of the policy.
2. If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the Insured Person shall have the right to choose insurers by whom the claim to be settled. In such cases, the insurer may settle the claim with contribution clause.
3. Except in benefit policies, in cases where an Insured Person has policies from more than one insurer to cover the same risk on indemnity basis, the Insured Person shall only be indemnified the Hospitalisation costs in accordance with the terms and conditions of the policy.
Since your claim amount does not exceed the sum insured under the earlier policy, contribution clause does not apply as the Insured has the option to choose the policy under which he wants to claim. As such we are not liable to make any payment under our policy for the said claim.
Regards
Hi deepesh, you’re saying a group cover should be complemented with a top up cover and not a separate independent cover as is normally suggested? The independent cover will carry over post retirement among other benefits from what i understand.
Hi Vijay,
1. If possible, complement your group cover with a regular health cover (personal or independent). This is the most preferred option. You can renew regular health plan well into retirement. When you want to enhance health cover under personal plan, you can consider super top-up plans.
2. If you find premium of the regular plan too high, complement your group cover with a super top-up plan (and not top-up plan). However, do note that not all super top-up plans allow you to convert to regular plan (zero deductible) at retirement.
Hope that answers your question. Let me know if you need any clarification.
Hi Deepak,
Very informative post!
My husband and I are both covered under group insurance policies from our respective companies. Both the policies have a maternity capping (20% of sum assured) Can I make my balance maternity claim (ie after settlement from my group policy) from my husbands group policy cover?
My husbands TPA says that I cannot claim from his policy as due to to the 20% capping, my sum assured is not getting exhausted and that my husbands policy is liable to pay only over and above the sum asssured under my policy under IRDA guidelines.
This seems a little unfair as first they put capping and then refuse to accept the claim as sum assured is not exhausted. Please clarify.
Hi Vidhi,
Thanks!!! Glad you found the post useful.
Yes, this is strange. In my opinion, wrong too. They are interpreting the regulations in the wrong way.
IRDA clause is for the insurers. The insurers cannot invoke contribution clause under the Sum Insured is exhausted. This does not apply to policy holders.
Take claim settlement letter from the first insurer and file for reimbursement with the second insurer (along with claim settlement letter from the first insurer).
You will get the balance amount from the second insurer.
You can ask TPA to refer to page 82 of IRDA Health Insurance Regulations, 2013. Ask them where is it written that you cannot claim from the second policy. Clause 5(r)(iii) talks about excedding Sum Insured after considering deductible or co-pay. The same argument can be extended to sub-limits or caps too.
In cases of such disputes, e-mail communication is the best so that you have track record. Drop e-mails to the insurance company and TPA and seek written reply. This way they will have to put thought into what they are writing. Otherwise, they will keep giving random reasons.
Your case is strong. Don’t give up. Keep escalating to higher authorities. If that does not work, drop e-mail to CEO of the Insurance company. If that does not work, escalate matter to IRDA.
Thankyou so much. The TPA is now agreeing to settle the claim after I showed him the IRDA Guidelines. 🙂
Wow!!! That is great news. I didn’t expect TPA to be so efficient. 🙂
Congrats. Am really glad.
If I buy a medical insurance policy for 10 lacs in the current year , while renewing the same policy after the waiting period of 2/4 years , is the insurance company likely to make changes in the policy with regards to any claims made before the waiting period?
As an example, say if someone gets a high cholestrol level in the second year of the waiting period . As this person is likely to have illness related to the heart, so during renewal will a medical test be conducted and will the medical insurance company make changes in the policy related to heart disease.
The ailments that you develop since the inception of the policy do not affect your premium. Moreover, there is no waiting period for such diseases. Waiting period is for pre-existing illnesses, not those illnesses that you got after the cover started.
Even if you make any claims (before or after waiting period gets over), the insurance company cannot increase the premium just because you made the claim.Claims base loading of premium is not permitted by IRDA.
So, essentially, your health condition at the time of inception of policy is a determinant of your premium amount.
This is why it is advised that you purchase health insurance at a young age. At the time, you are likely to be healthy and hence insurer will not load premium. Any ailments diagnosed since inception do not affect your premium.
The insurance company can increase the premium based on age though.
No medical tests will be conducted unless you are planning to increase the Sum Insured.
Hi Deepesh,
Very nicely written article and solved in many of my queries.
Still request to kindly guide me for Maternity case. I have a group cover from my office where max limit for maternity expenses is Rs. 5000.
I Also have a another policy from Max Bupa Heartbeat Gold policy. Where the Maternity cover is of Rs. 40000.
Please suggest and confirm can i opt for both the policies and also for which policy i should go for.
Hi Shekhar,
Thanks Shekhar.
You can claim from both policies. You mentioned maternity cover for group policy is Rs 5,000 (I assume that’s the correct number).
With MaxBupa, it is Rs 40,000.
Yes, you can opt for any policy.
Since the medical bill for delivery will run much higher than Rs 5,000, it makes sense to claim under Max Bupa cover (otherwise you will have to spend time and effort in claiming from the second policy).
If the bill is more than Rs 40,000, you can claim reimbursement from the group employer cover.
Hi Deepesh
I have a case where I have two maternity policy for my wife .One from her office and other from mine .I have taken cashless policy from my wife policy at the time of delivery and got 50,000 INR which was the maximum limit .
Now I had paid 63000 in total so I applied for 13000 INR reimbursement as reimbursement from my policy .For mine 35000 is the maximum limit .
What insurance company is stating that since the maximum cover is 50,000 which is already given I can’t get the rest 13000 since it is over and above 50,000 .
They state that there is some recent changes in policy by IRDA according to which the maximum cap for maternity is 50,000 only .
Can you clarify is they are correct ?
Anuj
Hi Anuj,
There is no such cap on maternity expenses. It is a plain lie. Ask them to point out to the relevant clause in the health insurance regulations. They will shut up.
One of the readers had faced a similar issue. You can go through my response to Vidhi’s comment.
In fact, her TPA agreed to look into the claim.
Hi Deepesh
Thanks for your reply ! I followed up with insurance agencies and my company HR .They both are very much pressing on that the claim can not be processed as they say my sub limit has exceeded . So as per them since both policy had a sub limit of 50,000 so maximum I can claim is 50,000 in total which I have already claimed from my wife insurance .So i can’t claim the 13000 since it is over and above 50,000 sublimit .
Is there any IRDA link I can send them as proof ,or is it possible that my policy is like that ?? Please provide some links for this so that I can pressurize them .
Thanks a lot for your help though.
Hi Anuj,
No point talking to company HR. They can’t help.
Talk to TPA. TPA cannot reject claims. They are not allowed to as per IRDA guidelines. Remind TPA of these regulations and
ask them to forward your request to insurance company.Tell them you will escalate to IRDA and their license will be revoked.
Let the insurance company take call.
Do not talk to anyone. Drop e-mails and escalate. This way you will have written record. If somebody calls you to clarify, ask them to reply over e-mail and cite relevant clauses under IRDA guidelines which say such claim cannot be honored.
Escalate to insurance company CEO. If he does nor respond, escalate to IRDA.
Refer to my reply to Vidhi’s comment on this post. I am copying an excerpt.
You can ask TPA to refer to page 82 of IRDA Health Insurance Regulations, 2013. Ask them where is it written that you cannot claim from the second policy. Clause 5(r)(iii) talks about exceeding Sum Insured after considering deductible or co-pay. The same argument can be extended to sub-limits or caps too.
In cases of such disputes, e-mail communication is the best so that you have track record. Drop e-mails to the insurance company and TPA and seek written reply. This way they will have to put thought into what they are writing. Otherwise, they will keep giving random reasons.
Can you please share your email or drop me an email to anuj324@gmail.com .I am really stuck . They have sent an communication which states that “It is clarified that the limit fixed under policy is the maximum amount claimable per maternity. For example both the spouse are covered for Rs 50000 each under the same or separate policies ,they can claim maximum Rs 50,000 on account of maternity .”
There is an attachment from Regional manager R.P. Sharma United India Insurance Co. Ltd. which I can send you on email .
I have though raised matter with IRDA and contacted
S. P. Asthana
Chief Manager,
Uni Customer Care Department,
Head Office, Chennai.
Tel:044-28575261
They are looking into matter and will advise accordingly .What more can i do now that they have given in written that the max claim can only be 50 ,000 .:(
I really appreciate the way you reply in detail .That gives me hope 🙂 .Thanks.
Anuj
Dear Anuj,
You have already taken the right steps. This remains a grey area.
In my opinion, both companies should pay. Let IRDA take a decision.
Keep following up with them.
You can drop e-mail at support[at]personalfinanceplan.in. However, there is little I can add.
You are already doing I would suggest.
Legal recourse is simply not worth it.
Hi Deepesh,
My recent hopitalisation cost was 7.46 lacs of which 3 lacs was paid my employee cover and 2.4 lacs from group insurance critical illness cover. I paid 1.07 lacs which I claimed from ICICI Pru (8 yesr old) which should cover up to 5 lacs. They have settled only 32 thousand yesterday. When I asked for the rationale this is what they are saying : “… Disallowances non-medical :- 15117
Discount given 61721
Disallowances adjusted with Discount Hence total discount is 61721-15117= 46604 .
Total payable before Copay is 762442-46604= 715838 on which 20 percent Copay applied which is 143168 ( 715838-143168)= 572670
Hence total payable as per us is 572670 -540000= 32670 which is payable
Copay is applied as the Hospital Room rent (Deluxe Room ) is more than 1 percent of Sum Assured in Network Hospital ..”
Isn’t it strange that they are considering the total amount for instead of the amount 1 lacs + for which for which I raised a claim? If there is any rule or guideline on this, please advise me on it.
To clarify – Single occupancy room was a necessity to avoid infections. The policy is a Unit Linked health saver plan
What does discount mean?
Rs 3 lacs + Rs 2.4 lacs + 1.07 lacs is not equal to Rs 7.46 lacs.
or am I missing something?
If you could also copy contribution and co-pay clauses from your ICICI plan, that will be useful.
Final Hospital Bill provides:
a) Bill Amount = 762442
b) I Paid = 100721
c) 2 discounts – 1) 49721 2) 12000 termed as IP Services Discount= 61721
Final Settlement (Insurance to Hospital): Amount Claimed:Rs 762442 Amount Settled:Rs 540000
Charge Type, Bill Amount, Payable Amount
Hospital Charges, 55500, 55500
Investigation & Lab Charges, 120320, 120320
Miscellaneous Charges, 15551, 15551
Surgery Charges, 228740, 228740
Consultant Charges, 7200, 7200
Pharmacy & Medicine Charges (Taxable), 335131, 335131
Total, 762442, 762442
(Less) Copay(Rs), 0
(Less) Policy Excess(Rs), 111165
(Less) Hospital Discount(Rs), 51277
(Add) Ser Tax (if Applicable)(Rs) 0
(Less) Early Paid Discount(Rs) 0
(Less) Tax Deducted at Source(Rs), 60000
(Less )Recovery(Rs), 0
Net Paid/Transferred(Rs), 540000
The copy contribution and co-pay clauses from your ICICI policy:
Cashless Facility: In network hospitals entitlement of single a/c room (room rent capped at 1% of annual limit per day) [Helpdesk confirmed that my room rent was within 1% of annual limit per day and the hospital was a network hospital]
Policy Doc – Page 19/40 No. 19: Network hospitals is a group of hospitals where services can be availed without Co Pay being applicable subject to policy terms & conditions. [helpdesk confirmed it was a network hospital]
Policy Doc – Page 20/40 Co Pay: Hospitalisation for any urgent medical and/or surgical treatment taken at a hospital for acute cardiac or accident or trauma to avoid serious impairment of health at an out of network hospital would be treated as within network claim and no CO PAY would be applicable. These claims would be considered to the extend of twin sharing rooms in an out of network hospital. In the event where the insured person has opted for any higher level of room type other than twin sharing room, co pay of 20% shall be applicable. [I had a heart failure and required immediate hopitalisation – referred to by my family physician]
Policy Doc – Page 20/40 Health Savings Benefits:The HBS (Whole Life Benefit) allows the policy holders to claim from his funds which are invested in Unit Linked funds of the company. This benefit can be claimed for below for below mentioned health care expenses for the insured under the policy…
– Co Pays or deductibles as part of the medical insurance cover
The benefit will become payable if [all conditions satisfied like 3 years after initiation, etc]
Policy Doc – Page 23/40 Contribution Clause: “Rate-able Proportion of any loss” means the part of the claim amount that will be payable by the company in cases where the policy holder is covered under more than one policy, the proportion of claim payable inclusive of co pay will be determined by the ratio of the annual limit under this policy to the total cover on the health of the insured person. The total cover refers to the sum of annual limits or sum assured applicable to the claim under all in force medical reimbursement policies. If at the time when a claim arises under this policy there is in existence any other insurance whether it be effected by or on behalf of any insured person in respect of whom the claim has arisen covering the same loss, liability, compensation, cost or expense, the company shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, compensation, cost or expense. [annual limit confirmed as 5 lacs by helpdesk]
Please note I requested for the 1 lac paid by me + 7K post hospitalisation expenses.
I have a few more questions.
I still don’t understand discount calculations.
However, if I accept their numbers, I think they have done the right thing.
As per them, the total expense was 7.16 lacs. After 20% co-pay, they are liable to pay upto Rs 5.72 lacs. Since we are talking about indemnity covers, you can’t get back more than what you have incurred. As per ICICI, your total reimbursable expense is Rs 5.72 lacs. You have already got Rs 5.4 lacs. Hence, they will pay only Rs 32,000.
Interesting part is that your total reimbursement would have been different if the your order of making claim was different.
If you have claimed under ICICI cover before group critical illness cover, ICICI Bank would have paid 2.72 lacs (and not just Rs 32,000). You could have claimed remaining part from your group critical illness cover. But, that’s past.
I have one doubt in this. Is your critical illness cover a fixed benefit cover (and not an indemnity cover)? Typically, critical illness plans are fixed benefit plans and have no relation to actual expenses incurred. However, the way you have written and ICICI has treated it, it looks like an indemnity plan. Please confirm.
If it is an fixed benefit plan, you might have a case.
Hi Deepesh,
Thanks for the post – well written and explains a complex issue in a simple manner.
I have my parents one of them is a senior citizen (63 years) and the other is (59 years). They are already covered by the company group policy of 3 lacs each. Where as I am wondering what could be a sound approach to manage the same.
Regards
Thanks Ajay. Glad you liked the post.
Has written a separate post on the topic.
http://www.personalfinanceplan.in/insurance/health-insurance-strategies-for-your-parents/
You might find this post useful.
Please share the posts you like with friends and family.
my mother age 55 already star health 2 lakhs 8 yrs running last 2 months back surgical 1 week bed hospital Bill amount 1.65 lakhs star claim 1.40 lakhs balance 25000 my pocket money expenses and medical expenese,medical test,scan test and lab test etc more bill 25000 amount total 50000 extra money expenses
1.my mother apply new health insurance topup plan or hospital cash 4000 per day benefit apply or not after that don’t claim reject ?
2.What is a general insurance health and life insurance health benefit details?
3.hdfc life or birla sun life hospital cash health insurance any multiple cliam already cliam star health same xerox copy bill hdfc life fixed amount received ?
Hi Deepesh,
My husband and I are both covered under group insurance policies from our respective companies.
My husband was hosptalised for a week & we have availaed cashless facility from my husband’s group policy. We had to pay some amount from our owm pocket due to 10% co-share & some non-consumable items not covered under the policy.
My question is whether can I claim this remaining amount from my group policy or not ?
Thanks & regards
Hi Neha,
This is a slightly tricky one.
If your group cover also have co-payment option, then there is no point making the claim. You won’t get the claim.
Even if group cover does not have co-payment option, TPA will initially decline to honor the request. You can force TPA to forward request to insurance company. The insurance company will also most likely decline.
You will have to escalate to IRDA or insurance ombudsman.
http://www.personalfinanceplan.in/insurance/what-to-do-if-insurance-claim-is-rejected/
Only IRDA or ombudsman will take a final call.
So, if the amount is small, don’t spend too much time on it.
If the amount is big, be prepared.
IRDA regulations are a bit gray on this topic. As I understand, your group cover should pay the remaining claim (if your husband’s treatment is covered).
Btw, no insurance company pays the entire amount. Certain consumables etc are never covered under any plan.
Hi Deepesh,
Thanks for your reply !
Yes, my group cover also have co-payment option. As advised I will not claim anything. But, I really fail to understand that how getting more than one policy helps a person. Even if I ignore the non-consumables, atleast I should be able to claim the co-payment after deducting 10% of this co-payment.
Anyhow, I really want to thank you for explaining everything and advising all the option available.
Best Regards,
Neha
You are welcome, Neha.
With co-payment (assume it is 10% or more in the second plan), you won’t get anything.
Group plan is something your employer decides. You don’t have much say.
In any case, claiming from two plans is never without hassles.
No. Think of it this way. Say your total bill is Rs 100. Rs 10 is consumables/non-consumables not covered under the plan. Of the remaining Rs 90, insurance company will apply co-payment clause and pay you Rs 81.
You go to the second company will claim settlement letter. They will again do a similar maths. Lets say the total amount to be paid as per the second company is Rs 85 (after applying co-payment). They know Rs 81 has already been paid by the first insurance company. They will settle only Rs 4.
If the amount is less than or equal to Rs 81 (as per second insurance company), you will not get anything from them.
For claiming this Rs 4 (and if it is Rs 4), you will have to fight a bit. You need to assess if it is worth it. It wouldn’t cost you any money but will eat up some time.
You are right Deepesh. That’s what happened last year when I got hospitalised & tried to claim co-payment of Rs.18000/- from second insurance company. After fighting & putting effort for almost 3 months, I got Rs. 4250/- only. That’s was quiet frustating even then. Hence, I will avoid wasting my time this time.
Many Thanks once again !
You are welcome, Neha.
I have had a Family Floater Mediclaim Policy since 2012 where I had taken Basic Insurance Value of Rs.200000/-( Two Lacs),later i had opted to enhance my Basic Insurance Value to Rs.500000/-(Five Lacs) in 2014. In between this my wife had met with hemorrhage and i had put a claim in 2013 for the same which was settled by the TPA. Now in 2016 my wife had to undergo the same treatment and i had put a claim of Rs.480000/-( Four Lac Eighty Thousand) but the TPA has only settled Rs.200000/- saying that it has not been 3yrs since the enhancement of BSI.
Can you please send me your inputs and guidelines?
Dear Sanket,
Waiting periods apply to enhanced Sum Insured too.
So when you increase Sum insured from Rs 2 lacs to Rs 5 lacs, this additional Rs 3 lacs would have a separate waiting period of 3 years. The timer will start from day of enhancement in Sum Insured.
I assume your plan has waiting period of 3 years for pre-existing illness.
As I see, in your case, three years have not lapsed since you enhanced the Sum insured. At the time of enhancement, your spouse had already undergone treatment for hemorrage. Hence, that may be considered a pre-existing illness.
You enhanced the cover in 2014 and only two years have lapsed. So, the insurance company is on firm ground.
Dear Mr Deepesh ,
Thanks a lot for such a wonderful article and many of my queries which I had been searching in many sites were answered by you in this article .
Kindly give your opinion to help me take decision . I am 39 years old and have got 2 individual health insurance policies for more than 5 years , New india Assurance mediclaim 2012 for 5 Lakhs and Icici Lombard complete health insurance for 4 Lakhs with top up plan for 8 Lakhs , with no claim . Recently last week in hurry I took Apollo Munich optima restore plan for 10 Lakhs thinking to have one with sufficient cover for future . I came to know of portability only yesterday .. Now I want to quit one plan as I don’t want to have 3 plans .. Pls help me choose between New India and Icici Lombard plans which one to continue and which to quit . I hope Apollo optima restore is a unique plan and I want to continue with 10 lakh SI till old age . Kindly give your opinion
Hi Vidhya,
You are welcome!!! Appreciate your kind words.
Yes, even I prefer having a big cover with a single plan rather than having small covers under multiple plans.
Btw, why do you think Apollo Munich Optima Restore is a unique plan?
What was the hurry to purchase a new health plan?
It is better if you make the decision yourself. I will guide you. It will help you in the long term.
Can you provide information about the following?
1.Years of purchase of these plans
2.Premium that you are paying for each plan
3.Waiting periods for pre-existing illnesses under respective plans.
4.Any existing illness
5.Any major illnesses diagnosed after purchase of each plan
6.Any sub-limits (daily cap on room rent, cap of specific treatments)
7.Did you go through medical checkups at the time of purchase of the plan?
8. Accumulated no-claims bonus under ICICI and New India plan
You have mentioned you have never claimed under these plans.
I assume all the plans are individual plans (and not family floater plan). Correct if I am wrong.
If you are an employee, does your employer also offer you health cover?
Thanks a lot Mr Deepesh for your reply and your time .
I took New India Assurance plan by 2007 paying a premium of around 8000 for 5 lakh cover And ICICI Lombard complete health plan in 2014 paying a premium of 7000 plus for 4 lakh cover . No claim in both policies till now . Recently I read about ” loading on premium may go up to 200 percent in Icici Lombard . That’s why I quit the idea of increasing SI in that plan and took Apollomunich plan thinking it would be easy to manage the premium in my 60 s after retirement . I said its unique because with no claim , Sum assured increases by 50 percent in that . Right now I m healthy with no medical conditions . did not undergo any medical tests while taking the policies . And I don’t have any cover from my employer . Kindly give your opinion which one to continue and which one to quit .
And in Icici Lombard policy I have got no claim bonus of 2 lakh extra sum assured i addition to original 4 Lakhs .
In new India policy no claim bonus points for 9 years I have got . All r individual policies . Waiting period of both policies were over and now I have got full cover .. Just thinking of future after retirement after 20 years , I think to have only one policy with large sum assured which I can manage to continue . Thanks in advance Mr Deepesh . So very nice of you to answer my query
Hi Vidhya,
If I were you, I would have increased cover in one of the existing plans rather than going for a new plan.
I don’t see any increase in premium (loading) for ICICI Lombard plan.
Btw, loading can even happen with Apollo Munich plan in the future.
Coming back to your question, New India plan has room rent sub-limit which can be a problem if you live in a big city and want to get treatment staying in premium rooms. However, PSU insurers have negotiated treatment rates with many hospitals and you may be able to get treatment at a lower rate (your Sum insured will deplete at a slower pace).
You need just one plan.
Let the New India plan lapse.
Further, there are two options.
1. Increase Sum Insured under ICICI plan to 10 lacs and let Apollo Munich plan lapse.
2. Let ICICI plan lapse and continue with Apollo Munich.
I prefer increasing the Sum Insured in ICICI plan because you have been in this plan for many years.
Dear Mr Deepesh ,
Thanks a ton for clearing my confusion . I have finally decided to do as you suggested to keep one plan with large SI . So very nice of you to clear my confusion finally .
With lots of regards ,
Vidhya
You are welcome, Vidhya.
Please share the post with friends and family.
Hi Deepesh
I have read your replies and would like to thank you that you are so kind in responding to everyone.
My query could be same with any other person here but I would like to have your views on this please.
I had made a claim of Rs 235000 for my mother surgery in my employer policy which has a co-pay clause of 30% so accordingly my TPA settled the claim for Rs. 164500 after deduction co-pay.
Now I preferred claim under my mother’s individual health policy of different insurer for claiming balance Rs. 70500 (co-pay amount) so can the insurance company deny the claim of Rs 70500. If yes under which policy conditions. Please note that individual policy does not have any co-pay and claim is otherwise admissible also as policy is being running since last 7 years.
Hi Shishir,
It depends on the policy terms and conditions.
Good that your mother’s individual plan does not have co-payment clause.
Other issue could be of room rent sub-limit.
Suggest that you go through the following post.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
You will get an ideas. Subsequently, you can go through terms and conditions of the plan.
If there is no co-payment and there is no room rent sub-limit issue, then you will get the claim.
Hi Deepesh
Thanks for your reply.
Individual Policy is from oriental insurance for 1 lakh sum insured . As far as policy T&C is concerned yes there is a room rent limit of 1 percent. But as mentioned earlier their is no co-payment clause.
But OICL is saying that claim is not payable as your SI for another policy was not exhausted and co-pay of one policy can not be claimed from any other insurance company. Please note that the policy under which I had preferred claim first, was for 3 lakh sun insured and total claim amount was 2.35 lakhs.
Request your views please that whether OICL is right in denying the claim. However they have not given any written confirmation for claim rejection till date.
Copying excerpt from IRDA Health Insurance regulations, 2016
If two or more policies are taken by an insured during a period from one or more insurers to indemnify treatment costs, the policyholder shall have the right to require a settlement of his/her claim in terms of any of his/her policies.
1. In all such cases the insurer who has issued the chosen policy shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
2.Claims under other policy/ies may be made after exhaustion of Sum Insured in the earlier chosen policy / policies.
3.If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount.
Looks like Oriental Insurance has a point.
However, this aspect and the language used is subjective. It can be argued both ways.
Suggest you drop an e-mail to grievance redressal cell of Oriental Insurance.
After a written response from them, you can approach IRDA or insurance ombudsman.
However, in my opinion, you are unlikely to get anything because of room rent sub-limit in your individual plan.
Hi Deepesh,
Very Informative article. I am stuck in the same situation as above Vidhi and Anuj for Maternity case. Me and my wife working in different company both having insurance from respective company, limit for maternity is Rs. 50,000/ .I have taken cashless policy from my wife policy at the time of delivery and got 50,000 INR which was the maximum limit . I had paid one lac plus in total so I applied for 50000 INR reimbursement as reimbursement from my policy .
What insurance company is stating that since the maximum cover is 50,000 which is already given I can’t get the rest amount as per Contribution clause. They are saying Employee can only claim the maximum limit under any policy.Also they added In my case, the limit for maternity is Rs. 50,000/- against both the policies that I hold and hence my claim for the balance amount is rejected.
Please guide me also explain, what is Contribution clause? are they are right?
Hi Kumar,
This is a grey area. Perhaps only regulator can clarify.
Btw, Contribution clause has been done away with in Health insurance regulations 2016.
Suggest you go through the following posts.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
http://www.personalfinanceplan.in/insurance/what-to-do-if-insurance-claim-is-rejected/
Revised regulations are more crisp. Somehow,I feel insurer has a strong case now.
But still, will suggest you escalate to IRDA and seek their view.
Hi,
My father undergone hip replacement surgery cost of this is 3 lac. Myself have corporate insurance of 1 lac for him and my brother have corporate insurance of 3 lac (approval for this surgery 1 lac). In hospital they will not take 2 insurance for one admission.
So can I use cashless from my brother insurance upto 1 lac and is that possible I can reimburse for the remaining bills. Please help me in this regard.
Hi Rohini,
You can claim from both policies.
As I understand your brother’s policy has a sublimit of Rs 1 lac from hip replacement surgery.
Your policy does not have any such sub-limit. Cover under your policy for your father is only Rs 1 lac.
Now, these sub-limits can create a whole lot of confusion.
Suggest you claim from your policy first (cashless) and then seek reimbursement under your brother’s plan.
Sometimes, the order in which you make the claim can determine the amount you get.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
Better still, talk to the insurance companies and seek clarity.
Please do update me about the response from the insurance companies. Other readers will also benefit.
Hello Sir,
Firstly, thank you for such an informative article. It’s been very helpful.
Kindly help me out with some information I’m not clear of.
In National Mediclaim Poicy, there is a capping of 1% of Sum Insured on room Rent. And then there’s no claim bonus, like 5% per year until it reaches 50% of SI. So, for instance my Basic SI is 5 Lakhs and I haven’t taken a claim for say 4 years, so my Sum Insured should be 6 Lacs by then, due to the no claim bonus I’d get for every year. Now when I take a claim, would I get room rent claim as 1% on Basic Sum Assured, (i.e. 5 Lacs) or 6 Lacs?
Also after I use my claim, say after 6 non claimed years or so, how does No Claim Bonus work? I don’t think it will still add up to maximun 50% of SI?
Dear Amit,
The room rent limit is typically a percentage of Base Sum Insured ( and not the enhanced Sum Insured).
So, it should be 1% of base sum insured.
Typically, in case of claim, no claim bonus gets reduced in the manner it accrued.
S, if you make claim this year, the total sum insured will go down from Rs 6 lacs to Rs 5.75 lacs.
Since your plan has room rent sub-limit, suggest you pick a room within the limit or else you will have to pay significant amount from your pocket. Suggest you go through following post to assess the impact.
http://www.personalfinanceplan.in/insurance/how-room-rent-sub-limit-can-affect-your-insurance-claim/
Okay, thank you
Also, Sir, does that mean all the capping/ sub limits are limited to only the percentage of Basic Sum Insured?
If so then how do we actually benifit from the amount accured through No claim bonus, which goes maximum till 2.5 Lacs?
There are expenses other than room rent when one gets hospitalized. Even though room rent stays the same, the excess sum insured can be used for other hospitalization expenses.
Thanks a lot, sir 🙂
Dear Deepesh
I have a Family floater for 7 lacs for myself and wife. Say at the age of 50 we decide to have Individual policy of 5 Lacs each from the same company we had family floater with in that case would I still have a waiting period?
Thanks in advance
Dear Manish,
You will get credit for waiting period already served when you shift from family floater to individual plan.
Hi deepesh,
I have the following query :
I hqd claimed an amount of Rs.90125 for the patient Neeta Mehta under a corporate group inssurance policy from National Insurance Co. Ltd. (TPA – Medi Assist India TPA Pvt Ltd) for hospitalization. The amount that was approved by National Insurance Co. Ltd. under the corporate policy was Rs 62781. ( i.e.70℅ and balance 30℅ shall be paid by the employee as per the corporate policy). For balance Rs.27344 , we have claimed under individual policy of New India Insurance Company which got rejected.
Can you please telle if I am entitled to receive Rs 27344 from New India insurance?
The reply I got from New India insurance company for rejecting the claim is this :
As per clause 5.6 of the Mediclaim 2007 policy as per IRDA guidelines, our contribution clause reads as follows :
CONTRIBUTION: If two or more policies are taken by the Insured Person during a period from one or more insurers to indemnify treatment costs, the Company shall not apply the contribution clause, but the Insured Person shall have the right to require a settlement of his/her claim in terms of any of his policies.
1. In all such cases the Company shall be obliged to settle the claim without insisting on the contribution clause as long as the claim is within the limits of and according to the terms of the policy.
2. If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the Insured Person shall have the right to choose insurers by whom the claim to be settled. In such cases, the insurer may settle the claim with contribution clause.
3. Except in benefit policies, in cases where an Insured Person has policies from more than one insurer to cover the same risk on indemnity basis, the Insured Person shall only be indemnified the Hospitalisation costs in accordance with the terms and conditions of the policy.
Since your claim amount does not exceed the sum insured under the earlier policy, contribution clause does not apply as the Insured has the option to choose the policy under which he wants to claim. As such we are not liable to make any payment under our policy for the said claim.
Thankyou in anticipation
Regards
Manan Mehta
Mananmehta028@gmail.com
Dear Manan,
Many have faced a similar issue.
It is the interpretation of point no. 2 which has led them to rejection of many claims such as yours. And this has happen across insurance companies.
In my opinion, this interpretation is not right and obviously skewed in favour of insurers. But guess we have to live with it.
I have covered this aspect in another post of mine. Suggest you go through the following post.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
You can take the matter up with IRDA too.
http://www.personalfinanceplan.in/insurance/what-to-do-if-insurance-claim-is-rejected/
Hopefully, you will get a favourable judgement.
Thank you Deepesh. I have mailed them exactly what you said in your earlier post.
Can you please provide me with your email id in case I have to ask you a few more queations.
Thank you in anticipation
You are welcome!!!
You can post your queries in the comments section itself.
Other readers may also benefit from your inputs.
Hi Deepesh,
My Dad had suffered heart attack so he had been implanted with 3 stents. Since my dad is working, under their company policy the approval amount per stent is only 65,000 where as we had requested to get a stent of 1Lac each. So the differential amount 35k per stent x 3 = 1,05,000 Rs had to be paid from our pocket. I have a policy coverage(a limit of 3lacs) for my parents in my company policy(TPA: UnitedHealth Care Parekh). From the hospital we have a detailed invoice, one separate authorisation letter from hospital stating extra 1.05lac has been paid by us and also another printed invoice of 1.05lac for paying through debit card. I had provided the discharge summary along with xerox copies of stent implant covers. I received an email from the TPA that they will need original stickers of stents, original tax invoice of stents and also Cardiac surgery investigation reports. The hospital had actually submitted the original stent stickers and surgery investigation reports to my Dad’s company. Hence I do not have them. Do you think I will still be eligible for the reimbursement as the originals are not there? Total hospital bill is around 4lacs including other charges. The detailed bill shows authorisation amount of 3lacs and extra deposit of 1.05lac. Pls guide me further course of action if they refuse to the pay the extra amount paid by us?
Hi Pratheek,
Claiming from two policies is quite complicated. There are many ambiguous areas.Would’t venture into those areas at this point of time.
Hospital can provide attested copies of bills, investigation reports etc.
About original stickers of stents, I am not sure. Have you talked to the insurance company about this?
As I see hospital bill was Rs 4.05 lacs and Rs 3.0 lacs has already been taken care of? Is that correct?
How much was your father’s total health cover?
Hi Deepesh
I found this article very informative, Also your instant replies to the queries are mind blowing. Thanks for all the good work.
I have a question,
My family have two group insurance (1. through my employer , 2. through my mom’s employer)
My father was admitted and the bill was 2 lacs. I claimed through my group insurance and I had a copay of 10%. Also due to previous claims, the company settled only 1.6 lac. So I had to bear 20000 copay deduction and additional 20000 as the limit exhausted.
We later claimed this 40000 through my mom’s Insurance. They now say copay amount will not be covered and they can settle only 20000.
Is that true that copay can’t be claimed through second insurance?
Appreciate your response.
Regards
Rakesh
Hi Rakesh,
There are many ifs and buts when it comes to claiming from two policies.
Btw, does our mother’s insurance also have co-payment clause?
Thanks for the prompt reply, My monther’s Insurance is free from co-pay.
Would it be possible to explain some cases of ifs and buts?
Dear Rakesh,
In that case, in my opinion, you should get the claim. You have a strong case.
It is a problem when second policy has co-payment clause.
Suggest you go through the following post.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
Will give you a fair idea how settlement works across multiple policies.
Go ahead and fight for it.
Don’t talk to TPA. Talk directly to the insurance company.
Ask the insurance company to cite clauses in Health Insurance Regualations which they are using to reject claim (or settle lesser amount).
Do keep me updated.
Again a nice write up, thanks for the info, will keep you posted.
Regards
Rakesh
Hi Deepesh,
Thanks for efforts put in by you. The article is very informative. I too have one query.
My wife and I both are covered in our corporate medical insurance respectively as primary and dependent. We get 50K and 35K as C-section maternity benefits from our policies.
My wife had a C-section and the total medical maternity expense is INR 98,290.
It includes Mother’s expense = INR 85,673
Baby’s expense= INR 12,617
I have got INR 50,000 as cashless claim from First TPA (settlement letter is awaited). For remaining amount, I have applied to other TPA.
The second TPA is only considering my wife’s expenses as a part of claim (i.e INR 85,673). Also, It is deducting INR 60,713 [50K (cashless claim amount + INR 10,713 (Surgical pads, diet and non-medical expenses)] from this amount. Therefore, I am only getting INR 24,960. as claim from second TPA.
Are they doing this split correctly? Please help in this regard.
I believe I should get Baby’s expenses and other expenses too.
Regards
Amit
fellow IIML
🙂
Sorry the second TPA figure is 45K instead of 35K.
Hi Amit,
Must say you are lucky. Many have approached me with similar cases where the second insurer has declined to settle any claim.
Policy wordings specify the exact nature of coverage. Hence, you may have to revisit it.
Typically, medical expenses for the baby are considered if he/she is part of the insurance plan (if your plan has new born baby cover). And the baby has to be admitted for some treatment (which I don’t think was the case). New born was merely in observation along with the mother.
Under standard definition for Maternity expenses from IRDA, it covers medical expenses for delivery and pre-natal and post-natal medical expenses. In my opinion, it is limited to expenses incurred for mother’s treatment. By the way, even “Medical expenses” has a definition.
Typically, consumables are not covered by any plan. So, diapers, food,pads etc are not covered. Non-medical expenses are also not covered. Hence, no point following up for this expense.
Think insurers are right in your case.
Btw, I would have replied even if you weren’t from L 🙂
Please do share the posts you like on your social media pages.
Happy Diwali… 😀
Thanks for the prompt reply Deepesh.
I know you will reply Deepesh 😀 its just that whenever I meet college people, it brings good memories of iimL days. 😀 😀
My baby will get enrolled in the insurance (the process is started). Its good you mentioned that new baby screening test is mere observation and will not cover. I didn’t knew that.
Also, My second TPA guy is asking for Settlement letter and attested copies of claim from first TPA before 3rd Nov (which is 21-25 days from delivery date). And first TPA guy is asking for more time saying lame excuses (office is closed for 1 week). How can I save my second TPA claim if this is delayed by first TPA?
Are TPAs obliged to follow a time line as per IRDA? if so please guide me to respective guidelines. Or a way to avoid this delay.
Regards,
Amit
Hi Amit,
I know.
First of all, TPA only facilitate. They can’t make decisions on the behalf on the insurer.
It is common for TPA to provide convenient excuses.
You can directly talk to insurer if they provide such lame duck excuses.
Typically, intimation has to be made within reasonable time. Such details are provided in the policy document. You must abide by what is given in policy document.
What is mentioned over there? If the policy documents puts such restrictions, it is better to expedite the process with the first insurer.
To expedite with first insurer, get in touch with insurance company. Mark a copy to Insurance company CEO, if you can find his/her e-mail id.
Too much delay in submitting documents can compromise insurer’s ability to investigate a claim. Better to expedite things.
Hi Deepesh,
Sorry for the delayed reply. The matter is resolved. I asked to loop in CEO of insurance to tackle the delay. It worked!! The 1st TPA accelerated his process. The second insurance TPA gave the INR 24960 as the final settlement. Also, They approved some additional claim for my baby’s expense.
Thanks for your help.
Amit
You are welcome, Amit.
That’s great!!!
Hi Deepak,
we are in a tricky situation. Need your advise on the same. My In law had Renal transplantation and the same is availed through Govt provided free insurance(say X) for which we didnt pay any premium. It was availed as cashless. As part of same hospitalization, we had charged few more tests and medicine which was not covered in policy X, so we paid it and total sum went to 1L. We have original prescription, Reports, Hospital Detailed breakup for the same.
Now, we have another private insurance policy(say y) under which the patient covered for 1L. We tried to claim 1L under this, they are asking for the Settelement letter from the previous insurance. But we dont have settlement letter from X as it is free scheme.
In this situation how can we proceed with the claim for additional expenses we got. Please note these additional expenses are covered by (policy Y). Only problem with settlement letter.
Regards
Rajesh
Sorry Deepesh i called you as Deepak. Please dont mind.
Don’t worry about it.
Dear Rajesh,
The second insurance company will ask for settlement letter. There should be something that proves that only a part of the claim has been settled. Please understand health insurance plans are indemnity plans.
Explain your case to the insurance company (and not TPA) and seek their response on the same.
Btw, was the patient covered under CGHS?
Thanks Deepesh for the reply.
Patient is not covered under CGHS.We have detail break up from hospital only for the unpaid amount.
Hmmm…am not sure how to take it forward.
Talk/write to the insurance company and explain your case.
They might suggest an alternative.
Hi Deepesh,
I also have a similar situation. My dad used to work with government company and post retirement my dad & mom get subsidies treatment (non CGHS) in network hospitals, with some reimbursement subject to capping for few specific treatments such as knee replacement.
Total subsidize expense for right knee replacement at Medanta was Rs 1,81,000 and we got reimbursement of Rs 75,00 from employer (government company – non CGHS). To claim balance amount private insurance company is asking for claim settlement letter. But on inquiring with government company they have denied to give any claim settlement letter as this is not part of their SOP and no one never asked for it.
Can I use my bank statement as a proof of settled claim? where reimbursement of Rs 75,000 has came from government company.
Hi Ankit,
Amount was settled by your father’s employer or by the insurance company?
The employer must give something. If possible, write to higher-ups in that company.
Write an e-mail to the insurance company (don’t just talk to the customer care). Write to grievance cell too and ask them an alternative in this case.
E-mails sometimes work like magic.
Hi Deepesh,
Amount of 75k is settled by father`s employer. As it is a government department so no one listen to common man, trying to highlight case with higher-ups, but my dad is in fear that to take revenge they would not blacklist or stop subsidy/medical benefits to us.
As it was a planned surgery, hence from day one I am in touch with Insurance company via emails and have documented each and every discussion between us. Today I have written email to insurance company that my father employer has denied to give claim settlement letter and have also requested them If as a proof I can give them undertaking with photocopy of passbook (in which I have received reimbursement amount). Lets see what response I will get. Just wanted to ask, what kind of action I can take if insurance company stick to their requirement of claim settlement letter from employer.
In last I just wanted to say thanks to you. very few people at your level take time out to help common man. You are doing good work 🙂
Thanks Ankit!!!
Let’s see what response you get from the insurance company.
Which is the insurance company?
Where are the original documents? With you or the employer?
If the documents are with you, go ahead and file a claim with the insurance company.
Ask the insurance company (mark an e-mail to the CEO too) the kind of letter they need from the employer.
It is very much possible that even if you get the letter from your employer, it may not be enough for the insurance company.
I am not sure if you can seek such info under RTI. If nothing works, give it a shot.
Hi Deepesh,
1. I have health insurance from Chola MS.
2. Original documents are with employer as they has provided subsidize treatment plus reimbursement of 75k. RTI is one of the route, only issue is you get highlighted in the department and then face difficulties in future processing.
3. On my mail insurance company has replied that they have assigned an executive who will get in touch with me within 2-3 working days.
Hi Ankit,
If you do not act strong now, this will become a permanent problem for you.
Whenever you claim from your father’s employer, you will not be able to claim from the insurance company.
Unless they can furnish you the original documents and provide settlement details, you will perhaps not claim from them in the future.
So, you need to push for the docs.
Visit them and tell them that you need those documents to get the remaining cost settled (I am sure you have already done that).
Do engage with the insurer and see what they say. Talking to customer care won’t help much though. They can give only rote answers. You need to escalate to grievance cell and explain your case.
Hi Deepesh,
I have a query. Me and my brother are working in different company and we have provided with the respective Medical Insurances from different insurers (L&T and Paramount).
While going for cashless the settlement bill amount is not exceeding the sum insured of L&T but i have to pay the co-payment for this as per the policy norms.
Is it possible to claim the co-payment(L&T) whatever i have paid to the hospital from the second Insurer Paramount?
Because I am paying the premium for both the Insurance companies.So i should be able to claim the co-payment from other insurance company right.
Regards,
Prakash M
Dear Prakash,
Suggest you go through the following post. You should get your answer.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
Btw, Paramount is not an insurer. It is a TPA.
Here is what is mentioned in Health Insurance regulations, 2016
If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount.
Many insurers have interpreted this clause as you can’t claim from second insurer unless your Sum Insured under the first plan is exhausted. Hence, if the second insurer also has a similar interpretation, you will not get anything from the second company. Btw, this aspect is quite subjective. You can escalate to IRDA if the second insurer declines to honor. I assume there is no co-payment in the second plan.
Hi Sir,
I have a query. Me and my wife are working in different company and we have provided with the respective Medical Insurances from different insurers
(I met accident on 15-10-2016 discharge today)While going for cashless the settlement bill amount sum insure exhausted, my wife working in COGNIZANT insurer is New India my wife SI limit is 250000 my bill around 605603 after deducting co-pay 20% 117068 non medicals 20265 and Rs.137533 SI Exhausted, and am working in Star Health Insurance i having GMC for SI rs.250000 with national insurance tpa is Vidal Health can i get the copay amount of rs.117068 from my poliy because TPA denied to pay the co-pay amount as per IRDA
Need your help on this still am in hospital
Dear Dheeresh,
This is a subjective area. I have see insurance companies taking different stance on such matters.
My understanding is that the second insurance company should pay even the co-payment amount (if the second plan does not have any co-payment clause).
Suggest you talk to the insurance company (and not the TPA). TPA CANNOT reject your claim on its own.
Ask them which IRDA regulation prohibits them from paying co-payment amount (ask the specific clause).
Thank you so much sir for your valuable informatin
Is the contribution clause applicable in super topup policy also with base insurer?
For Eg. Suppose I have an Base Insurance of 7.50 lakhs along with Cumulative Bonus of 2.50 lakha & Super Top Up Policy cover of 20 lakhs with 5 lakhs deductible & if i get a claim of 15 lakhs how this will be settled??
Dear Yogesh,
Contribution clause has been done away with in Health Insurance Regulations, 2016.
Hence, you don’t need to focus on contribution clause.
Suggest you go through the following post.
http://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
Hi Deepesh,
This is very informative for me.
I am also facing the same issue waht Anuj and Vidhi faced last year. Me and my wife has seperate Mediclaim policy with our respective organisation. In both the places we have capping of 50,000/-. During meternity the expenses were around 94,000/-. Firstly I have claimed the amount from my wifes organisation (United India insu)and they settled 49500/-. Then I submitted the claim document to TPA (For oriental). But they are not ready to settle remaining amount. TPA has given below response. Could you please help me out with how to handle this.
Thanks
Amit
Thanks Amit!!!
This is a grey area. You can follow the same process as Vidhi followed.
A point to note is that TPA cannot reject claims. Only the insurance company can.
Search for “Amit” in the same post. You will find an example where both insurance companies settled claim in a similar case.
You should take a similar approach.
Marking e-mail to CEO of the insurance company can get you a fair treatment.
Below is the response received from TPA
With reference to the captioned claim, you may please note that Maternity benefit under mediclaim is event based and maximum permissible is Rs.50,000/-only, either it paid by our company or any other company. This is for your information
TPA cannot reject claims. Ask them to get this from insurance company.
On a different note, birth of a child is a great phase in life . Money will come and go. It is time to rejoice. 🙂
TPA did not rejected the claim. They have shared the response what they have got from Oriental Insurance. Is there any way to get it done. I am definitely enjoying fatherhood :). Thats most beautiful phase of life.
Hi,Deepesh,
I have a mediclaim policy for One lakh since the last 15 years. I had renewed the policy to rupees 3 lakks four years back and I have been paying the enhanced premium since then. I am 68 years old and I am having a total knee replacement . I wish to know whether I am entitled to 1 lakh or 3 lakhs. claim. The cost of the surgery and hospitalisation is around 3 lakhs.
Would appreciate an early reply.
Thanking you.
Dear Sir,
For a few planned treatments such as knee replacement, hernia etc, there is typically a waiting period of 2-4 years. Please understand this is different from waiting period for pre-existing illnesses. This period has to be served by everyone.
For the enhanced portion, you will have to service this waiting period again.
However, since you enhanced the cover 4 years back, I believe you would have already finished this waiting period for an enhanced portion of Rs 2 lacs.
Therefore, you should get coverage for Rs 3 lacs for your knee replacement surgery.
Please go through policy wordings. Waiting periods are mentioned over there.
Hi Deepesh,
I wanted to confirm regarding Maternity insurance from two insurance provider. Me and my husband are working in two different company and having insurance from Medi Assist covering 50K and Reliance General Insurance which is covering 75k.
Now the total bill was 1.5 Lakh which is exceeding the total covered amount. Hence we will be willing to claim from both the insurance company. I was thinking to got for reimbursement process from both insurer. But Medi Assist has told that it will not be possible.
Can you suggest if I go for cashless transaction from Medi assist and then later i will apply for Reimbursment with the Second insurer. Will this work ? OR do we have to go for either cashless or reimbursement from both the insurer.
Hi Ruchi,
This is pot luck.
If you go through other comments, a few have succeeded in getting claim processed from both insurers while others have struggled.
IRDA regulations are a bit subjective in this matter (subject to interpretation).
MediAssist is a TPA. Don’t go by what they say. Seek clarity directly from the insurance company (will be good if you mark a copy to CEO too).
I believe 50K and 75K are maternity cover sub-limits under the overall plans.
About the order, better to go with the higher cover amount (Rs 75K). Lesser hassles.
Or alternatively, seek clarity from both the companies. Go first with the one that does not allow reimbursement if it is the second insurer.
My Father had a CRT-P (pacemaker) transplant done and the Hospital bill was around 5,95,000/-
I have my employer provided group insurance cover from United Health Parekh of 6L and I had also opted for 4L top-up. Also this has a co-pay of 20%. I also have another individual insurance from Star Health for my father with 2,50,000/- cover.
Since the bill is more than 2.5L I will be submitting my reimbursement claim with United Health. I am not sure but I expect around to get claim for around 4.5L considering the cop-pay and other non-medical expenses.
My question is that whether I can claim the remaining amount (around 1.5L) from Star Health?
Also i have star health insurance for about 7 years now… will the transplant have any implication on premium for next renewal?
Hi Ritesh,
First the easier question. Claim will not affect your next year’s premium.
The maths behind claim from two policies can be quite complicated.
Suggest you go through the following post.
https://www.personalfinanceplan.in/insurance/how-claim-is-settled-in-case-of-multiple-health-insurance-plans/
In my opinion, you can claim from both policies. Suggest you go first with employer plan and then personal plan. However, do go through the above post and see tricky it can get.
Hi Deepesh
Thanks for a very informative post.
I need your guidance on how well private Health Insurance work for a CGHS covered person. what type of health insurance will be better for such person and what are the ways to utilise the both in an efficient manner
Thanks.
Hi SIR
I have a case where myself and my wife work in the same company but having two different group insurance policy .I have taken cashless policy from my wife policy at the time of delivery and got 25000 INR which was the maximum limit .
Now I had paid 53000 in total so I applied for 19000 INR reimbursement as reimbursement from my policy .For mine 25000 is the maximum limit .
What insurance company is stating that since both the persons are working at the same company only one person policy will be applicable , and I cannot claim the reimbursement.
is there any such rules and regulations as per IRDA. PLEASE SUGGEST ME HOW TO DEAL AND CLAIM THE REMAINING AMOUNT