Can You Claim Health Insurance From Multiple Companies?

For the past few days, you have been complaining of pain in your stomach and have decided to get a full-body check-up. After the diagnostic centre handed over the report to you and you visited your doctor, your physician advised you to undergo surgery as he/she noticed tumours developing inside your stomach. The doctor further informed you that the entire treatment would cost around Rs 7 lakhs. 

You started worrying about the costs but remembered you have health insurance from two companies. This situation leaves you wondering whether you can claim health insurance from multiple companies for the same medical expense. Let’s find the answer.

Understanding the ‘contribution clause' under health insurance 

Submitting claims with multiple health insurers was always allowed whether it was health insurance plans for family or an individual. The IRDAI introduced a contribution clause to make the process smoother and ensure uniformity. According to this clause, insurers must share the medical bills in proportion to the sum insured they offer.

For example, if you incur medical expenses of Rs 80,000 and have two health insurance policies, one with a sum insured of Rs 4,00,000 and another with Rs 1,60,000, the insurers will share the claim based on their respective sum insured amounts.

In this case, the insurer with the Rs 4,00,000 policy will pay 71% of the claim (Rs 56,800), and the insurer with the Rs 1,60,000 policy will pay 29% of the claim (Rs 23,200). 

However, after 2013, this clause is no longer valid, and policyholders have the option to raise the first claim with any of the insurers they deem fit.

Types of claims in health insurance 

Before we understand how claims with multiple insurers work today, let's first look at the types of claim options available.

1. Cashless Claim: Health insurers have partnered with noted healthcare facilities across India. These hospitals, also known as network hospitals, allow you to get treatment without paying anything upfront except for the deductibles. The insurer directly settles the bill with the healthcare establishment.
2. Reimbursement Claim: In this type, you are required to pay for all the expenses incurred during your treatment, from room rent to doctor’s consultation and visit charges. After paying the bills upfront, you need to collect the related invoices and other documents and submit them along with the claim form. The insurer will review your claim request and process the reimbursement amount.

How does a claim with multiple insurers work?

Let's consider an example to understand this concept better.

Suppose you have two health insurance plans: one with sum insured of Rs 5 lakh and another with a coverage of Rs 3 lakh. After a few months of buying the policies, you are diagnosed with a heart disease requiring immediate surgery.

The doctor has provided an estimated cost for coronary artery bypass graft surgery of around Rs 6 lakh. Here is the ideal way to raise the claim —

1. Identify the network hospitals of your primary insurer and admit yourself for the surgery. The insurer offering Rs 5 lakh coverage will settle the amount up to the sum insured directly with the hospital. You will be required to pay the deductible amount and the balance of Rs 1 lakh.
2. Gather all the invoices, a discharge summary from the hospital, and a claim settlement letter from your primary insurer.
3. Next, approach your secondary insurer, complete their claim form, and submit the documents above.
4. The secondary medical insurer will review the claim and process the reimbursement. However, you will also need to bear the deductible amount set by this insurer.

Points to keep in mind when buying multiple health insurance

1. Ensure the secondary policy you buy provides some added coverage or features that you believe are necessary and are not provided by the primary insurer.
2. Go through the deductible clause. It is the amount associated with the claim you need to bear before your insurer covers the medical bills. You may prefer a higher voluntary deductible amount in your secondary policy to reduce your policy premium.
3. Ensure there is no co-pay clause in the policy, as it would make getting medical care financially burdensome.
4. Remember, you can’t claim the same amount twice from different insurers. Insurance plans are meant to reimburse you for the actual cost incurred, so the combined payout from multiple insurers cannot exceed the total bill.
5. Each health insurance policy has its own terms and conditions, including exclusions, limits on specific treatments, and waiting periods. Be sure to review the terms carefully before filing claims with multiple insurers.

Conclusion

With healthcare costs steadily rising, having more than one health insurance plans for the family can be a smart financial move. Yes, you can claim health insurance from multiple companies, but the process is structured to ensure fairness for both you and the insurers. Following the proper steps, you can maximise your coverage and ensure you are not left bearing large out-of-pocket expenses after a medical emergency.