aj-s
1

Hi Group, We are expecting a new member to family and these times are exciting but it comes along with host of medical expenses.
Me and my wife are both working with corporate insurance policy, can someone please help how can i claim both the insurance policy maternity covers for the expenses.
My company insurance policy has ₹10 Lac sum insured both for me and my wife with ₹75k maternity benefit and my wife company insurance policy has ₹4.5 Lac sum insured both me and my wife with ₹50k maternity benefit.
Although my corp policy has high sum insured and good maternity benefit but the hospital we shortlisted has higher band of package for delivery (around ₹1.5L for normal and ₹2 L for c-sec). If we go with my wife’s policy the package at the same hospital is lucrative (around ₹65k for normal and ₹95k for c-sec). I went ahead and got a pre approval from my wife’s policy and they have provided pre-approval of ₹38k (of the ₹65k estimated by hospital for normal).
Please help if anyone has detail understanding on how cashless and reimbursement works in case claiming 2 policies for treatment. I am sure this is the very norm in society where both couples are working and want to make best benefit of the policies.
I read that if insurance is claimed from 2 policies, the larger sum insured would cover, in my case, maximum of 7.5/12 of the total medical cost incurred capped under maternity benefit and room tariff if i go with my policy as cashless treatment and then go ahead with reimburse remaining from my wife’s policy (that probably would be 4.5/12 ratio).
I will keep both the insurance providers in the loop for claiming the expense, but I am not certain from whom should i go with as cashless treatment and with whom as reimbursement.

Thanks in advance.

From India, Pune
PROFESSIONALS AND BUSINESSES PARTICIPATING IN DISCUSSION
Saswatabanerjee
Partner - Risk Management
+1 Other

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saswatabanerjee
2319

I do not think you can claim the expense for the same medical issue from 2 different insurance companies, as it would amount to a fraud.

the insurance company will ask for original invoices to be given to it and will also have its TPA verify the transactions. So you will need to chose one of the two

From India, Mumbai
aj-s
1

I confirmed this well and have kept both insurance policies TPA in loop about it and they have no concerns about it. It is in written email. It isn’t fraud.
From India, Pune
saswatabanerjee
2319

If you already have approval from both insurance companies that you are allowed to claim the money from both of them, then what is the problem? I thought you were asking if it can be done or not.
From India, Mumbai
aj-s
1

true, but as i mentioned above, i am not certain what calculation goes into it and if someone had experience of claiming it this it would be great to know. Moreover, i need help/suggestion to which should be kept primary (cashless) and secondary (reimbursement). Hope this clarifies.
From India, Pune
vibhakar
77

1. Please check if wife, or in some cases husband, can opt out of medical schemes and increase his/her take home pay.
2. Coverage by H and W is not a secret. May be the Employer or the Insurance Company can be ignorant. Both H and W better talk to their employer and sort out.
3. In any case, Insurance Companies insisit on originals. So claiming double amount on same bill is not possible.
4. This possibility can be tried, declare the maternity to both insurance companies and claim 50% from each Insurance Company.
5. We are not doing anything illegal. Such difficulties can always be come over.

Vibhakar Ramtirthkar.

From India, Pune

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