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Claim settlement by multiple insurers

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15 Aug, 2021 by  Pawan Musale

I have two health policies for parents-one by my employer and other individual policy. Both have 20% copay and Rs 20000 limit for cataract. Say if I have to claim for cataract procedure, i will claim to retail policy where they will pay 16k. Can i claim balance 4k to other policy? If yes will I have to pay 20% of balance 4k out of pocket? Can you pls help understand.

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16 Aug, 2021

Hi Pawan,


Yes and Yes to your both queries.

Just to add 2 more points:

  1. I am sure you would have spent on doctor consults, diagnostic tests etc prior to surgery. Those expenses are also claimable. So along with 4k pending payable from surgery claim, the OPD expenses also you must file for reimbursement.
  2. Remember that since the original hard copies will be submitted to 1st insurer, you will need to request them to send to you hard copy of settlement letter on insurer's letterhead and copies of claim documents with insurer's seal/stamp on them. These will be required for submission in 2nd claim.


Happy to answer any followup queries.


Anuj Jindal

Co-founder

SureClaim

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16 Aug, 2021
Pawan Musale
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16 Aug, 2021

Hi Pawan,


Since cataract is a treatment which already has a sub-limit in the policy, the co-pay clause is not applicable to it.


So as per my understanding, the entire 4k (as per your question) will be paid from the second policy and no co-pay will be applicable.


Regarding your question around OPD:


Any OPD expenses incurred before or after a covered treatment can be claimed under pre-post hospitalization expenses.


Stand alone OPD expenses (not leading to hospitalization or covered treatment) is not payable in a policy not covering OPD.


Hope this helps!


Cheers :)


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17 Aug, 2021
Pawan Musale
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