I have two health policies — which one should I claim from first?

With two indemnity policies, you choose which one to claim under first; that insurer becomes the primary insurer and, if its cover is not enough, it must coordinate with your other insurer to settle the balance as per the policy conditions. With benefit policies that pay a fixed amount, such as a critical illness policy, you can claim under all of them. Disclose the other policy when you claim, and keep certified copies of the papers for the second claim.

You may hold two policies: one from an employer and one bought personally, or a top-up alongside a base cover. IRDAI sets out how a claim works across both, but the choice of where to start is yours.^[1]

How the choice works

IRDAI's health master circular says a policyholder can file a claim under any policy of their choice, and the insurer of that policy is treated as the primary insurer. If the cover under that policy is less than the admissible claim, the primary insurer must seek the details of your other policies and coordinate with the other insurers to settle the balance as per the policy conditions.^[1]

Benefit-based policies work differently, because they pay a fixed amount when the insured event happens rather than reimbursing the bill. For those, you can claim from all insurers under all policies.^{[2, 1]}

Things to weigh before choosing

ClaimAssure does not recommend one policy over another. These are points worth weighing, and the answers are in your two policy documents.

• Limits and co-payment: Sub-limits, room-rent caps and co-payment in each policy decide how much of this bill each one would pay.
• Bonus on the policy you claim under: A claim can reduce an accumulated bonus. One insurer's product, for example, reduces the cumulative bonus at the same rate at which it accrued.^[3]
• Cashless at your hospital: If only one policy has your hospital in its network, starting there may avoid paying first.
• Renewal afterwards: An insurer cannot refuse to renew a health policy because you claimed, except a benefit policy, such as critical illness, that ends once its benefit is paid. Renewal loadings on individual products are set for the whole portfolio, not on your own claims.^[2]

How the balance claim works

1. 1

   Claim under the policy you chose

   File the claim with the full set of papers, and say that you hold another policy.

2. 2

   Get the settlement advice

   Ask the first insurer for its settlement letter showing what it paid and what it did not.

3. 3

   Claim the balance under the second policy

   Where the originals went to the first insurer, one insurer's wording accepts copies certified by that insurer together with its settlement advice.^[3]

4. 4

   Disclose the other insurance

   One insurer's wording requires you to disclose other insurance when you claim.^[3]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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