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Claim overlapping two policy periods

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16 Aug, 2021 by  Avinash Sonee

Hi,


Suppose there is a health insurance policy no. 2020/xyz which is valid from 22-07-2020 to 21-07-2021. On 14-07-2021, the customer has renewed the policy. The renewed policy no. is 2021/xyz which is valid from 22-07-2021 to 21-07-2022.


Coincidentally, the customer has got hospitalized on 18-07-2021 and discharged on 28-07-2021.


For this hospitalization,

  1. does the customer have an option to claim from either of the policy?
  2. shall the claim be paid only from policy period in which date of admission falls? i.e. pol no. 2020/xyz
  3. shall the claim be paid only from policy period in which date of discharge falls? i.e. pol no. 2021/xyz
  4. shall the claim be paid equally from both policies?
  5. shall the claim be paid prorata from both policies? (if yes, is the calculation as simple as dividing by the number of days falling in each policy period or is it based on the actual charges encountered on each day which can become complex and is subjective)
  6. what if the above policy is a top-up policy? how's is the deductible calculated?


Thank you

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17 Aug, 2021
dinesh jain

In such cases, the most important thing is what is the date of hospitalization ?


In your case, the customer was hospitalized on 18/07/2021. So irrespective of when he/she is getting discharged, eligible sum insured will be the one which is from 22/07/2020 to 21/07/2021.


So the claim be paid only from policy period in which date of admission falls (for claim discharge date does not matter).


Thus claim will not be paid equally from both the policy rather only from the policy (during which the admission has happened).





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17 Aug, 2021

Hi Avinash,


The claim will be paid from the policy in which the date of admission falls. So in this case the 2020-2021 policy.


Hope this helps!


Cheers :)

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17 Aug, 2021
Avinash Sonee

Hi,


Thank you Dinesh Jain & Kiran Karkera for your answers.


Is this a standard regulation across all health insurance policies and is this a recent change?


Because if I take an example of old Star Health Comprehensive plan (with UIN: IRDA/NL-HLT/SHAI/P-H/V.III/398/14-15), it mentions that

If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles for each policy period. Such eligible claim amount to  be payable to the insured shall be reduced to the extent of premium to be received for the renewal/due date of premium of health insurance policy, if  not received earlier. This is applicable for claims falling under Section 1 only.

whereas the next revision (with UIN: SHAHLIP2077V041920) or the latest revision (with UIN: SHAHLIP22028V072122), I couldn't find any mention about 'Claim under two policy periods'.


If it is not a standard regulation, what happens if there is no mention about 'Claim under two policy periods' in the policy document / wordings / clauses.


Thank you

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17 Aug, 2021
Avinash Sonee
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