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"Can we claim health insurance from two companies?" This is a question that often pops up on forums like Quora, reflecting a common concern among policyholders in India. The good news is, yes, absolutely! In India, it is perfectly legal and, in many cases, beneficial to have multiple health insurance policies and to claim from more than one company. With rising medical costs, having additional coverage can provide a much-needed safety net.
However, understanding how to navigate the claiming process when you have multiple policies is crucial to ensure a smooth experience and avoid any rejections. This guide will walk you through everything you need to know.
Step 1: Understand Why You Might Have Multiple Policies (And Engage with Your Situation!)
Before we dive into the "how-to," let's consider why you might even have more than one health insurance policy. Does any of this sound familiar to you?
QuickTip: Pay attention to first and last sentences.
- Employer-Sponsored Group Policy + Personal Policy: This is a very common scenario. Your employer provides you with a group health insurance plan, but you've also invested in a personal policy for broader coverage, higher sum insured, or specific benefits that your group policy might lack.
- Multiple Personal Policies: Perhaps you started with a basic policy and later felt the need for more extensive coverage, or you wanted to diversify your risk across different insurers.
- Top-Up or Super Top-Up Plans: These are designed to kick in after your base policy's sum insured is exhausted, providing an additional layer of protection for large medical bills.
- Family Floater + Individual Policy: You might have a family floater for your family and an individual policy for yourself for higher coverage, especially if you have specific health concerns.
No matter your situation, having multiple policies can be a smart financial move. The key is to understand how to leverage them effectively when the need arises.
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Step 2: Know the Golden Rule: No Double Profit!
This is the most fundamental principle: You cannot make a profit from your insurance claims. This means you can only claim up to the actual amount of your medical expenses, even if the combined sum insured of your policies is significantly higher. Insurance is designed for indemnification – to put you back in the financial position you were in before the loss, not to enrich you.
Reminder: Short breaks can improve focus.
Step 3: Choose Your Approach: Cashless vs. Reimbursement
When making a claim with multiple policies, you essentially have two routes, just like with a single policy:
Sub-heading: Cashless Claims (The Direct Settlement Method)
This is often the preferred method as it involves less out-of-pocket expense for you.
Tip: Write down what you learned.
- How it Works: In a cashless claim, your insurance provider directly settles the hospitalization bills with the network hospital.
- The Multi-Policy Twist: When you have two or more policies, you'll typically initiate the cashless claim with one primary insurer.
Sub-heading: Reimbursement Claims (Pay First, Get Paid Back)
If you're treated at a non-network hospital, or if your cashless request is denied/partially approved, you'll go the reimbursement route.
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- How it Works: You pay the hospital bills upfront, and then you submit all the necessary documents to your insurer(s) for reimbursement.
Step 4: The Step-by-Step Guide to Claiming from Two Companies
Here's a detailed breakdown of the process:
QuickTip: Read again with fresh eyes.
Sub-heading: Scenario 1: Medical Bill is within the Sum Insured of One Policy
If your total medical expense is less than or equal to the sum insured of one of your health insurance policies, you can choose to claim from that single policy.
- Select Your Primary Policy: Decide which policy you want to claim from. Often, people choose the policy with the higher sum insured or the one with a more favorable claims process/history.
- Follow Standard Claim Procedure: Initiate the cashless or reimbursement claim as you normally would with that chosen insurer.
- For Cashless: Inform the hospital and your chosen insurer about your hospitalization. The hospital will coordinate with the insurer for pre-authorization.
- For Reimbursement: Pay all bills, collect all original documents, and submit them to your chosen insurer along with the filled claim form.
- Claim Settlement: The insurer will process and settle the claim as per their terms and conditions, up to the sum insured of that policy.
Sub-heading: Scenario 2: Medical Bill Exceeds the Sum Insured of Your First Policy
This is where having multiple policies truly shines. If your medical expenses are higher than the sum insured of your primary policy, you can claim the balance from your secondary policy.
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Step 1: Initiate Claim with Primary Insurer:
- Inform Both Insurers: As soon as hospitalization occurs (or is planned), it's highly recommended to inform both your insurance companies. While you'll initiate the formal claim with one, transparently informing both can prevent issues later.
- Choose Your Primary Policy: Select the policy you want to use first. Many people opt for the policy with the highest sum insured or the one that offers cashless facility at the hospital you are admitted to.
- Follow Cashless or Reimbursement Process:
- If Cashless (preferred for higher amounts):
- Get admitted to a network hospital.
- The hospital will send the pre-authorization request to your primary insurer.
- Once approved, the primary insurer will settle the claim up to their sum insured.
- Crucial: Before discharge, ensure you obtain the original hospital bills and discharge summary, and a "Claim Settlement Summary" or "Denial Letter" from the primary insurer clearly stating the amount paid and the balance remaining (if any). Ask for attested copies of all documents that the first insurer keeps.
- If Reimbursement:
- Pay all hospital bills yourself.
- Collect all original documents (bills, reports, discharge summary, prescriptions).
- Submit these original documents to your primary insurer along with their claim form.
- Once the primary insurer settles, they will typically return your original documents with their "Claim Settlement Summary" or "Payment Advice" clearly showing the amount paid. Make sure you get these originals back or certified true copies.
- If Cashless (preferred for higher amounts):
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Step 2: Claim the Balance from Your Secondary Insurer:
- Gather Required Documents: For your secondary claim, you will need:
- A copy of all original hospital bills (attested by the primary insurer or hospital, if originals were kept by the primary insurer).
- The original "Claim Settlement Summary" or "Payment Advice" from the primary insurer, clearly stating how much they paid.
- Your secondary insurer's claim form, duly filled.
- Copies of your discharge summary, lab reports, prescriptions, and any other relevant medical documents.
- A letter explaining that the expenses exceeded the first policy's sum insured and you are claiming the balance from them.
- Submit to Secondary Insurer: Submit all these documents to your secondary health insurance company.
- Secondary Insurer's Assessment: The secondary insurer will review the documents, particularly the settlement summary from the first insurer, and process the remaining claim amount, subject to their policy terms and conditions (e.g., sum insured, sub-limits, deductibles). They will pay the balance up to their policy's sum insured.
- Gather Required Documents: For your secondary claim, you will need:
Step 5: Important Considerations and Best Practices
- Transparency is Key: Always disclose all your existing health insurance policies to every insurer when purchasing a new policy. This is mandated by IRDAI regulations and is crucial for smooth claim settlements. Non-disclosure can lead to claim rejection.
- Coordination of Benefits (COB): While less common as a formal process in individual policies in India compared to some Western countries, the concept still applies. Insurers coordinate to ensure the total payout doesn't exceed 100% of the actual medical expenses.
- Pro-Rata Clause (for Indemnity Policies): Some older policies or specific clauses might have a "pro-rata" condition, especially if you were under-insured relative to the total value of the "risk" (though less common in health insurance where the "risk" is medical expense). However, for health insurance, as long as you're not claiming more than the actual bill, this usually isn't an issue.
- Deductibles and Co-payments: Remember that each policy might have its own deductibles (an amount you pay before the insurer pays) and co-payments (a percentage of the bill you pay). These will apply to each claim individually.
- Record Keeping: Maintain meticulous records of all your policies, communication with insurers, claim forms, original and attested copies of bills, discharge summaries, and settlement letters. This will be invaluable in case of any disputes.
- Time Limits for Intimation: Be aware of the time limits specified by your insurers for intimating them about hospitalization and submitting claims. Delays can lead to rejection.
- Claim Settlement Ratio: While buying, consider the claim settlement ratio of insurers. A higher ratio generally indicates a smoother claim process.
By following these steps and keeping transparency at the forefront, you can effectively claim health insurance from two companies in India, ensuring comprehensive financial protection during medical emergencies.
10 Related FAQ Questions
How to choose which health insurance policy to claim first?
- Generally, prioritize the policy with a higher sum insured, better cashless network, or one that covers more of the specific treatment costs you've incurred. If cashless is an option, pick the insurer with a tie-up at your chosen hospital.
How to ensure both insurance companies are aware of each other?
- When filling out the proposal form for a new policy, always declare your existing health insurance policies as required. For existing policies, you can inform your insurers in writing about any new policies you acquire.
How to handle a cashless claim where the primary insurer only pays a part of the bill?
- Get the "Claim Settlement Summary" from the primary insurer and attested copies of all original hospital bills and documents. Then, submit these along with your secondary insurer's claim form for reimbursement of the balance amount.
How to get original documents back from the first insurer for the second claim?
- In a reimbursement claim, the primary insurer should ideally return original documents after processing, along with their settlement letter. If they insist on keeping originals, request certified true copies from them and ensure the settlement letter clearly details the payment.
How to claim if one policy is an employer's group policy and the other is personal?
- You can choose to claim from either first. Employer policies often have cashless tie-ups. If the employer policy covers the full amount, great. If not, use its settlement summary to claim the balance from your personal policy.
How to manage deductibles and co-payments when claiming from two policies?
- Deductibles and co-payments will apply as per each individual policy's terms. The primary policy's deductible will be met first, and then the secondary policy's deductible (if applicable) will need to be met before their coverage kicks in.
How to avoid claim rejection when using multiple policies?
- Be transparent about all your policies, submit all required documents accurately and on time, and ensure you are not claiming more than the actual medical expenditure.
How to claim if both policies are reimbursement-based?
- Pay all hospital bills. Submit original documents to your primary insurer. Once they settle, obtain their settlement summary and certified true copies of all original bills and reports. Then, submit these copies and the primary insurer's settlement summary to your secondary insurer for the balance.
How to approach a situation where the secondary insurer asks for original bills that the primary insurer kept?
- Politely explain that the original bills were submitted to the primary insurer for their claim settlement. Provide the certified true copies obtained from the primary insurer or the hospital, along with the primary insurer's detailed settlement summary. Most insurers understand this scenario.
How to find out if my policies have a "Contribution Clause"?
- Review your policy documents carefully. Most indemnity health insurance policies in India have a "Contribution Clause" which essentially means if you have multiple policies, the insurers will share the liability for the claim proportionately based on their respective sum insured, but only up to the total actual expense. This is why disclosing all policies is critical.
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