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Ramalingam Kalirajan |7911 Answers |Ask -Follow

Mutual Funds, Financial Planning Expert - Answered on Jun 18, 2024

Ramalingam Kalirajan has over 23 years of experience in mutual funds and financial planning.
He has an MBA in finance from the University of Madras and is a certified financial planner.
He is the director and chief financial planner at Holistic Investment, a Chennai-based firm that offers financial planning and wealth management advice.... more

Question by Ajay on Jun 09, 2024Hindi

Hi guru, My wife is pregnant now, expected delivery is on aug and the amount of delivery is around 2 lacks in Hyderabad. We both are corporate employees and holding corporate insurances, mine can be claimed upto 50k and my wife insurance can be claimed upto 70k As i came to know that we both cannot be submitted for cashless claim, Questions: Can we pay the total amount by cash and claim individual insurances by submitting the hospital bills? Can we go a head with my wife cashless claim for 70k and remaining bills can be submitted in my company insurance? Whats the best procedure to claim the both our corporate insurance benefits? Please suggest. Note: recently my friend submitted their both corporate maternity bills and has been claimed.

Ans: Congratulations on the upcoming addition to your family! It’s great that you and your wife have corporate insurance to help cover the delivery costs. Let’s explore the best way to utilize both insurances effectively.

Understanding Corporate Insurance Claims
Corporate health insurance policies typically have specific rules and procedures for claims. It’s crucial to understand these to maximize your benefits. Here’s a step-by-step guide to help you navigate the claims process:

Cashless Claim Option
Cashless claims are convenient as they reduce the immediate financial burden. However, there might be restrictions when using multiple policies for a single claim.

Reimbursement Option
Reimbursement claims require you to pay the hospital bills upfront and later submit the bills for reimbursement from your insurers.

Strategy for Maximizing Insurance Benefits
Option 1: Using Cashless and Reimbursement Together
Cashless Claim with Your Wife's Insurance:

Since your wife’s insurance covers up to Rs 70,000, you can opt for a cashless claim for this amount.
Inform the hospital in advance about the cashless claim using your wife’s insurance.
Reimbursement Claim with Your Insurance:

For the remaining amount, you can pay out of pocket and later submit the bills to your insurance for reimbursement.
Ensure you get detailed and itemized bills from the hospital to avoid any issues during the reimbursement claim.
Option 2: Full Payment and Dual Reimbursement Claims
Pay the Total Amount by Cash:

Pay the entire hospital bill upfront by cash or card.
Submit Bills for Reimbursement to Both Insurers:

First, submit the bills to your wife’s insurance to claim the maximum allowed amount (Rs 70,000).
Once the claim is processed, submit the remaining bills to your insurance to claim up to Rs 50,000.
Clearly indicate to your insurance that your wife’s policy has already covered part of the expenses.
Recommended Procedure
Step-by-Step Process
Contact Both Insurers:

Reach out to both your insurance providers to understand their specific claim processes and requirements.
Confirm if they accept combined claims and get clarity on the documentation needed.
Pre-Authorization for Cashless Claim:

For a cashless claim using your wife’s insurance, obtain pre-authorization from the insurer. This typically involves submitting a pre-authorization form to the hospital, which then coordinates with the insurer.
Documentation:

Collect all necessary documents, including the hospital bill, discharge summary, and any other medical reports.
Ensure the bills are itemized and clearly mention the amount paid.
Submitting Reimbursement Claims:

After your wife’s insurance processes the cashless claim, submit the remaining bills to your insurance for reimbursement.
Include a cover letter explaining that the initial claim was processed by another insurer and attach a copy of the claim settlement.
Additional Tips
Keep Track of Communication
Maintain a record of all communications with your insurers and the hospital. This includes emails, phone calls, and any written correspondence.
Follow Up
Regularly follow up with both insurers to ensure your claims are being processed. Prompt follow-ups can help avoid delays.
Seek Clarification
If any part of the claim process is unclear, don’t hesitate to seek clarification from your insurers. It’s better to address any doubts upfront to avoid complications later.
Conclusion
Using both corporate insurances effectively can significantly reduce your out-of-pocket expenses for the delivery. By opting for a combination of cashless and reimbursement claims or full payment followed by dual reimbursement claims, you can maximize your insurance benefits. Ensure you communicate clearly with your insurers, follow their procedures, and keep detailed records to facilitate smooth claim processing.

Best Regards,

K. Ramalingam, MBA, CFP

Chief Financial Planner,

www.holisticinvestment.in

DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Users are advised to pursue the information provided by the rediffGURU only as a source of information to be as a point of reference and to rely on their own judgement when making a decision.

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Question by S - Jun 21, 2022Hindi

Dear Sir, Greetings of the day. I have got a health insurance of family floater type from Tata AIG for a sum of four lakhs. Recently, I got hospitalised and full four lakhs was paid by Tata Aig. But my hospital bill was six lakhs and sixty two thousand. So there was a shortfall of two lakhs sixty-two thousands. I have an Aditya Birla health Policy of family floater type for 45 lakhs. But it will come in to effect after 5 lakhs expenditure. So I myself paid one lakh from my pocket. And for rest one lakh sixty two thousand only I applied for cashless to Aditya Birla .But they denied it. Finally I paid that amount myself and came home. Afterwards I kept continuous follow up with them. Reconsideration and reminder letter was sent by TPA and Treating doctor. But again it was rejected. Now Aditya Birla employee is saying apply for reimbursement. When Tata Aig is clearing full amount, how come Aditya Birla is denying it? And how can I bridge the gap one lakh between two policies? Tata Aig says you have taken full claim so we cannot make your limit from four to five lakhs this year. Pls advise suitably. Best Wishes

Ans: Hi Mr. Tripathi, greetings to you. To answer your first question as to why Aditya Birla won’t provide you with cashless claim as opposed to TATA AIG is because the policy you bought from Aditya Birla is a ‘Super top up plan’ which basically means it is an addition to your base policy which in your case is your TATA AIG policy.

Super top up policies do not offer cashless claims but only provide reimbursements.

The one lakh gap, unfortunately, cannot be filled at this point. However, while renewing your policy you can opt for increased sum insured with TATA AIG. The insurer will ask you a set of questions and schedule medicals to analyse your risk profile. Post that based on your reports, the insurer will take a decision on increasing the limit.

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Ramalingam Kalirajan |7911 Answers |Ask -Follow

Mutual Funds, Financial Planning Expert - Answered on Apr 16, 2024

Asked by Anonymous - Apr 04, 2024Hindi