Claiming Across Two Health Policies

Holding two health insurance policies — perhaps an individual plan plus an employer group cover — is increasingly common in India. When hospitalisation costs exceed one policy''s limit, or when one insurer rejects a portion, knowing how to claim correctly across both policies can save you a significant out-of-pocket expense. The rules are governed by IRDAI''s contribution clause guidelines.

The Contribution Clause Explained

When two or more health policies cover the same person for the same event, the contribution clause applies. Under it, each insurer pays only their proportionate share of the claim rather than the full amount — preventing you from profiting from a claim. However, IRDAI has clarified that you can choose which insurer to approach first and claim the balance from the second.

Step 1: Choose Your Primary Insurer

For a planned hospitalisation, decide which policy to use first. Factors to consider:

• Which insurer has a cashless tie-up with the hospital you plan to use?
• Which policy has a higher room rent limit or lower deductible?
• Which policy''s claim history can you afford to use (to protect no-claim bonus on the other)?

Step 2: Exhaust the First Policy

File the cashless or reimbursement claim with your primary insurer. Obtain the settlement summary showing the total bill, the amount paid by the first insurer, and the balance unpaid (due to sub-limits, deductibles, or sum insured exhaustion).

Step 3: Claim the Balance From the Second Policy

Submit a reimbursement claim to the second insurer for the unpaid balance. Documents required:

• Completed reimbursement claim form
• Original hospital bills and discharge summary (or certified copies if originals were submitted to first insurer)
• Settlement letter / Explanation of Benefits (EOB) from the first insurer showing their payment
• Proof of payment for the balance you paid out of pocket
• NEFT details

The second insurer will pay only the genuinely unpaid amount — not a duplicate of the first payment.

Getting Certified Copies of Bills

If original bills are with the first insurer, ask the hospital for certified photocopies and have the first insurer issue a letter confirming originals are on record with them. Most insurers accept this with the first insurer''s settlement letter as corroboration.

Common Errors in Dual-Policy Claims

• Filing the same expense with both insurers without disclosing the other policy — this is fraud and can lead to policy cancellation
• Not disclosing both policies at the time of hospitalisation — disclose all policies at the hospital''s insurance desk
• Assuming the second insurer pays the full bill again — they pay only the unpaid balance

Conclusion

Claiming across two policies requires transparency and organised documentation, but it is entirely your right and can make a significant difference when bills are large. If you are unsure which of your policies should be primary or how to frame the second claim, TruePolicy advisors can walk you through the specific order and paperwork for your situation.