Please note that as per IRDA New Rules – 2013 (the process of filing claims for people holding multiple health covers), the individual can file claim with either of the health care polices possessed by the individual in case the claim is less than or equal to the amount insured. With the new rules, the contribution clause only comes into effect when the claim amount is higher than the amount insured for one policy. (Earlier the individual has to inform both or all insurance companies for filling a claim and the companies who paid the insurance amount divide the claim according to the contribution clause.)
A. If two or more health insurance policies are taken by an insured
During a period from one or more insurers, the contribution clause shall not be applicable where the cover/benefit offered:
1. Is fixed in nature;
2. Does not have any relation to the treatment costs;
And all insurers will make payment independently. e.g. Critical Illness Plans, Hospital cash-benefit Health Plans, Personal Accident Plans
B. In case of multiple policies which provide fixed benefits
On the occurrence of the insured event in accordance with the terms and conditions of the policies, the insurer shall make the claim payments independent of payments received under other similar polices. e.g. Critical Illness Plans, Hospital cash-benefit Health Plans
C. If two or more policies are taken by an insured
During a period from one or more insurers; to indemnify treatment costs, the insurer shall not apply the contribution clause, but the policyholder shall have the right to require a settlement of his claim in terms of any of his policies. e.g. Mediclaim, Health Insurance (Reimbursement Plans)
1. In all such cases the insurer who has issued the chosen policy shall be obliged to settle the claim without insisting on the contribution clause as long as the claim is within the limits of and according to the terms of the chosen policy.
2. If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the policy holder shall have the right to choose insurers by whom the claim to be settled. In such cases, the insurer may settle the claim with contribution clause.
3. Except in benefit policies, in cases where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the policy.
How Specific Cases will be Claimed?
1. Group and Individual Indemnity policy:
In case you have group and individual (personal) indemnity both policies, then claim can be lodged with any of the two insurers. However, we recommend that you must first use the group claim limit. Because it will save your no claim bonus on the individual health insurance policy (i.e. no increase in premium at renewal).
If claim is large one and you need to log claim to both insurer then once the first insurer has processed the claim and made payment, the customer will have to write to the serving TPA that he would like to claim the balance. The TPA will then issue a settlement note and certified copies of original documents submitted by the customer.
2. Different Health Insurance Plans from Same Insurer:
If couple, who are working and have respective group insurance from their respective employer. Now in case of hospitalization, both of them can apply to their respective insurance firm for the medical expense.
3. Two different plans from Same Insurer:
If you have two different plans from the same insurer, understand both the policies coverage. Also check if there is TPA, having the same TPA for both the policies may be an advantage for claim settlement. The claim settlement will be easy for your, as claim documents for both the policies are managed by the same set of people.
4. Personal reimbursement plus fixed-benefit plan:
Typically, fixed-benefit plans such as health plans sold by life insurers and critical illness and disability covers pay on diagnosis. The policy lapses after the claim is settled. The process is usually different from that of regular indemnity plans, which settle claims on the basis of actual hospital expenses. Hence, one can make concurrent claims with fixed benefit and reimbursement plans.
Please note that in some policies (e.g. hospital cash benefit plans), the insurer needs the complete set of documents, for this the customer will have to take permission from the insurer to submit photocopies.
5. Two personal reimbursement plans:
If you have two reimbursement policies, the contribution clause only comes into effect, when the claim amount is higher than the amount insured for one policy. This means both insurers will pay in proportion to the coverage.
If you have declared that you hold another health policy in both proposal and claim forms, you need not inform the second insurer separately.
The first insurance company can settle the complete claim (up to the sum insured limit) and claim the pro-rata settlement amount under the ‘contribution’ clause of the policy from the second insurer.