Health Insurance

Surrender Kohli: My wife and I have health insurance covers from our respective employers. She has a cover worth ` 50,000 and I have a ` 40,000 insurance policy. My spouse is now pregnant. Can we claim maternity expenses from both insurers?

Mahavir Chopra, Director, Health, Life and Strategic Initiatives, Coverfox.com, replies:

In case of health insurance, a policyholder is allowed to make use of the sum assured from two or more policies whether the policies are from the same company or different insurers. One could be a group insurance policy offered by the employer and the other one could be his/ her personal policy. If the claim amount is greater than the sum assured under one policy, the insured can utilise other policies to raise the claim amount.

For instance, if a person has two policies of ` 2,00,000 each from insurer A and B, and he has a claim running up to ` 3,00,000, he can claim ` 2,00,000 from either by submitting all original documents. Then he should procure a settlement certificate from the insurer who has paid the entire sum assured and claim the balance from the second by submitting photocopies of the claim documents.

Sadly, the same does not hold good for maternity expenses. The reason: The maximum maternity benefit is capped at around ` 50,000 for caesarean delivery and around ` 30,000 for normal delivery, which can be covered by one or multiple policies. If you try to raise the claim from both insurers, they will invoke the condition of contribution, which means sharing the claim amount in proportion to the sums insured under their respective policies and ensuring that the total payable amount does not exceed the maximum limit.

The best possible solution is to contact both insurers and ask what is the maximum maternity benefit paid by them. After that, you can place your claim with the insurer providing the maximum benefit depending on your requirement ( normal or caesarean delivery).