17 Sep, 2021 | Health Insurance

A Step-by-Step Guide To Claims Process When You Have Two Health Insurance Policies

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By Team Beshak
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We love the Beshak Forum so much because it’s where we find some of the most interesting, pertinent and relevant questions about insurance. These questions from our community members help us understand how nuanced the insurance products such as health, life and critical illness insurance could be. For instance - there was a question from one member who had both a corporate/employer provided health insurance policy and a personal one. Now, he wondered how he should plan to go about a claim should it ever occur. Which plan to use first, and how? 

While we’ve written extensively about why a corporate health insurance plan might not be enough, and one must always invest in a personal plan as well… this question about the claims process with two policies (one personal and one employer insurance) was new, and we thought we must answer it once and for all too! 

In this quick article, we tackle questions like - Can I claim from both the policies? If yes, how? Which policy should I claim from first? If these questions have crossed your mind even once, read on… 

Claiming from two different health insurance policies

When you have two health insurance plans, you can claim from both if one of them falls short. The best way to know whether you need to use both policies is to get an estimate from the hospital in advance. Once you get this and find out that the sum insured in one policy might not cover the entire expense, you'll have to prepare to use two policies. 

Here’s how you make the most of both your health insurance plans.

Step One: Claiming from the first health insurance policy. 

Wherever possible, use the cashless claims process with the first policy. This will simplify your process dramatically - as you won’t have to go through the procedure of gathering documents, submitting it, following up with the insurer etc. The hospital insurance desk will manage the claim on your behalf. 

How does a cashless claims process work?

  1. First, you’ll need to confirm about the cashless availability at the hospital desk and get a checklist of all the documents (insurance policy copy/ card, PAN card, ID proof etc.) you’ll have to submit. Most hospitals will also accept these documents digitally, so always keep a copy of these documents on email for easy access. 
  2. The hospital will request the insurer to make an initial approval of the treatment cost on your behalf - this is also called pre-authorisation. In case there’s a holiday or the hospital desk/ insurer office isn’t open, this pre-authorisation may get delayed and you might have to pay an advance to get the admission. 
  3. As soon as you get to know about the discharge date, follow up with the insurance desk to submit all the bills and documents to the insurer. 
  4. It usually takes between 2 to 6 hours to receive the final approval from the insurer once all the paperwork is done. 
  5. In case the final approval is delayed, you’ll either have to wait until your claim is approved or you can pay and claim the amount later through reimbursement.
  6. The insurer will send you a claim settlement summary that will tell you whether your claim is approved or declined (and if approved, what part of the claim is approved too). 
  7. This document will have a detailed listing of all the expenses incurred during your treatment - what is approved, and what remains unapproved. This is super important to take - especially because you still have one more claim to make.

In case the hospital declines your request for a cashless claim or your prefered hospital is not on the insurer's network list, you’ll have to pay for the hospital bill from your pocket and then apply for reimbursement of those expenses. 

How does a reimbursement claims process work?

  1. You’ll first need to inform the insurer about the hospitalisation within 24 hours of getting admitted. (a day in advance for planned hospitalisations)
  2. Then, bring together all the original documents and bills required, and submit them to the insurer along with a duly filled claims form.
  3. If the insurer raises any queries or requests to submit any missing document, ensure that you do that as soon as you can. 
  4. The insurer will send a claim settlement summary where you can check the reimbursement amount and the deductions made with details of the line-items that were approved, and those that were not. 
  5. The reimbursement amount will be credited to the bank account you provided in the claims form. 

Step two: Claiming from the second health policy. 

Based on what is approved in the first claim and what is not - you’ll have to claim the remainder from your second policy. This will always be through reimbursement. 

After the claim from the first policy is settled, the insurer will return all the documents and bills for which they have not paid. They might, however, not release the original bills and receipts which they have settled. 

Now, when you apply for a reimbursement claim from your second policy, you’ll have to submit three things to the second insurer - 

  1. Photocopies of bills that were submitted and settled by the first insurer. 
  2. Original copies of bills that the first insurer did not pay for. 
  3. Claim settlement summary received from the first insurer. 

Which health policy should you claim from first?

In case both your policies are personal, you can claim from the policy with the higher sum insured first so that a majority of your claim can happen through cashless settlement.

However, if you have one corporate plan and one personal plan, it is better to exhaust your corporate sum insured first before using your personal policy. 

Here are some reasons why - 

  1. By first using your employer policy, you ensure that your personal policy cover remains intact. You can use it in case you need to take a break or leave your company in the middle of a policy year. 
  2. If you have taken a family floater for the personal policy, you can retain the sum insured for your family members.
  3. If, for any reason, you decide to port your policy, it will be much easier when you don’t make any claims from your personal plan.
  4. It will become difficult to upgrade your personal health cover once you make a claim from a policy. Upgrading is much easier when you remain claimless. 
  5. Lastly, if you opted for NCB (No Claim Bonus) while buying your personal policy, you can earn a bonus for not making any claims in a year.

Things to keep in mind if your employer health insurance sum insured is low

We just talked about how you should first exhaust your corporate health insurance cover first, then utilise your personal health cover. However, if your employer health insurance cover is low - say only around 3 to 5 lakhs, it will become important that you build an emergency health fund or have a good credit card that is active. This might come in handy, as you may have to pay some expenses out of your pocket - and get it reimbursed later from your personal policy.

For instance, if you undergo a hospitalisation that costs INR 6 lakhs but your employer health insurance cover is only INR 3 lakhs. In such a case, you’ll have to arrange for the remaining 3 lakhs and settle the hospital bill before getting discharged. 

Now, reimbursement can take a few weeks which is why it’s important that you either have an active credit card or an emergency health fund to support you during this time. Later, you can apply for reimbursement of these 3 lakhs from your second policy. 

An understandable question: If neither of the policies offers cashless, is it possible to claim through reimbursements from both policies?

Yes, you can claim through reimbursement from both policies. In such a scenario, you will have to wait to get reimbursement cleared from the first insurer and keep the second insurer informed about this through email. Note that you won’t get back the original bills that the first insurer approves and reimburses you for. 

So, as soon as the first insurer reimburses you and returns the remaining bills, you can submit them to the second insurer along with the claim settlement summary and apply for reimbursement. 

Got a question?

You can post it on our forum and get answers from insurance experts within 6-8 hours!

Key takeaways
  1. If you undergo a major hospitalisation and have two health insurance policies, you can claim from both if one of them falls short.
  2. In case both your policies are personal, you should claim from the policy with the highest sum insured first. 
  3. However, if you have one employer plan and one personal plan, as a thumb rule, you should claim from the corporate plan first and then use the personal policy.
  4. As far as possible, you should always claim from the first policy through cashless. 
  5. If cashless isn’t available or the hospital declines your cashless claim request, you can pay for the hospital bill and then apply for reimbursement.
  6. If you claim through reimbursement from both policies, you’ll have to wait to get reimbursement cleared from the first insurer and then submit the required documents to the second insurer.
  7. When you apply for a reimbursement claim with the second insurer, you’ll have to submit the claim settlement summary & photocopies of bills settled by the first insurer as well as original copies of bills the first insurer did not pay for.
Team Beshak
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We are a group of young members of the Beshak community. We come together to brainstorm, write relevant and useful content for people (just like us) who want to figure insurance on their own. If you too want to share inputs/write for us - send us a "hey" to info@beshak.org

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