Claim Process of Individual and Floater Health Insurance Policy

Though insurers have made the claim settlement process simple, by offering a cashless facility, there is a slight variation if you have two health insurance policies - an individual plan and a family floater one. So how would you go about claiming from each?

If you have two plans, you can use any plan to meet the claim if the claim amount is lower than the coverage in any plan. Experts believe that if you have two plans - one individual and one floater, at the time of a claim, you should first make a claim on your individual health insurance plan and then move on to the family floater plan if the claim is higher.

Utilizing your individual health insurance plan’s coverage first if you face a contingency would leave the floater plan to cater to your family’s requirements so that the coverage would not prove insufficient. If the claim amount can be met by your individual plan, do not use your floater plan and leave the cover intact for your family members. The floater plan should be resorted to only once you exhaust the coverage limit in your individual plan in cases of high claim.

So, individual first and floater later should be your ideal mantra. But how about claiming from the two when the need arises? There is a process, a protocol and it is to be followed. But the first two major points are -

Disclosure - If you have multiple plans, whether individual or floater, you have to disclose the same at the time of buying another plan. In short, the insurer should be informed about any existing health plan you have for yourself or your family. If not informed, the insurer might reject your claim on the grounds of non-disclosure in dire cases.
The contribution clause - This disclosure is required because insurers can opt for a contribution clause at the time of claim settlement. This clause is usually relevant in cases where the claim is of a considerable amount and has to be shared between the different insurers. As per the clause, invoked by the insurer, every insurer shares the claim burden in proportion to the coverage level granted. So, if you have an individual plan and a family floater health insurance plan of Rs.2 lacs and Rs.1 lac each, in case of a claim of Rs.2.5 lacs, the claim would be payable in the ratio of 2:1 respectively.

Process - Individual And Family Floater Health Insurance Plan

To explain the process, let us consider that you have an individual health insurance plan of Rs.2 lacs and a family floater plan of Rs.5 lacs.

Case 1 - A claim of Rs.1.75 lacs

Since the claim can be easily met by your individual plan, make a claim on the plan and get it settled. You would need to submit the original medical bills to the company and then only would the company settle your claim.

Case 2 - A claim of Rs.3 lacs

When the claim exceeds your individual coverage, you can claim the entire Rs.2 lacs on your individual plan and the remaining Rs.1 lac on the floater plan. In this case, first you would have to submit the original bills to your insurer with whom you have the individual plan. The insurer would settle the claim and submit a claim settlement form.

This form would be submitted to the other insurer along with the attested copies of medical bills (as the originals are retained with the first insurer). The other insurer would then settle the remaining Rs.1 lac. The insurers may also call for a contribution clause when you claim the amount simultaneously. But it is your choice to first get the claim settled from the one insurer and then the balance settled with the other one. The documentation should be followed and attestation on copies of the bills would have to be done by the hospital where the treatment was taken.

So now you know how to claim when you have two policies. Always remember to use your individual health insurance cover first before jumping to the family floater health insurance plan.