husband and wife maternity benefit claims from two insurance providers

Hi Group,

We are expecting a new member to the family, and these times are exciting, but it comes along with a host of medical expenses. My wife and I are both working with corporate insurance policies. Can someone please help me understand how I can claim both the insurance policy maternity covers for the expenses?

My company insurance policy has ₹10 Lac sum insured for both me and my wife, with ₹75k maternity benefit, and my wife's company insurance policy has ₹4.5 Lac sum insured for both of us, with ₹50k maternity benefit.

Although my corporate policy has a high sum insured and good maternity benefits, the hospital we have shortlisted has a higher package cost for delivery (around ₹1.5L for normal delivery and ₹2L for a c-section). If we go with my wife’s policy, the package at the same hospital is more attractive (around ₹65k for normal delivery and ₹95k for a c-section). I proceeded to get pre-approval from my wife’s policy, and they have provided pre-approval of ₹38k (out of the ₹65k estimated by the hospital for normal delivery).

Please help if anyone has a detailed understanding of how cashless and reimbursement work in the case of claiming two policies for treatment. I am sure this is very common in society where both partners are working and want to make the best use of their policies.

I have read that if insurance is claimed from two policies, the larger sum insured would cover, in my case, a maximum of 7.5/12 of the total medical costs incurred, capped under maternity benefit and room tariff if I go with my policy as cashless treatment, and then proceed to reimburse the remaining from my wife’s policy (which would probably be on a 4.5/12 ratio).

I will keep both insurance providers in the loop for claiming the expense, but I am not certain with whom I should proceed for cashless treatment and with whom for reimbursement.

Thanks in advance.

I do not think you can claim the expense for the same medical issue from two different insurance companies, as it would amount to 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 choose one of the two.

I confirmed this well and have kept both insurance policies TPA in the loop about it, and they have no concerns about it. It is in a written email. It isn't fraud.

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.

True, but as I mentioned above, I am not certain what calculation goes into it, and if someone has experience claiming it, it would be great to know. Moreover, I need help or suggestions on which should be kept primary (cashless) and secondary (reimbursement). Hope this clarifies.

1. Please check if a wife, or in some cases a husband, can opt out of medical schemes and increase his/her take-home pay.

2. Coverage by both the husband and wife is not a secret. Perhaps the employer or the insurance company may be unaware. Both the husband and wife should communicate with their employer to resolve any issues.

3. In any case, insurance companies insist on originals. Therefore, claiming double the amount on the same bill is not possible.

4. One possibility to explore is to declare the maternity to both insurance companies and claim 50% from each insurance company.

5. We are not engaging in any illegal activities. Such challenges can always be overcome.

Vibhakar Ramtirthkar.