Condition of contribution is a practice where if you have two policies insuring the same risk then the claim needs to be paid by both the policies
It’s always advisable to have a separate health insurance policy apart from the cover provided by your employer. First you may changeyour job and the new employer may not provide you with the same benefits, or the health insurance cover provided by the employer may be very little. An individual plan ensures you are sufficiently insured even when you are in and out of jobs, and in case your office policy is not enough.
The good thing is the rules allow you to use the second policy if you exhaust the cover in the previous one.
Suppose you have two health policies—basic indemnity plans that pay for hospitalization—one with a sum insured of Rs1 lakh and the other with a sum insured of Rs2 lakh. In case your bill comes to Rs2.5 lakh, you can exhaust the policy with a sum insured of Rs2 lakh and use the other one to pay the difference of Rs50,000. You can choose the policy you want to make a claim.
Also keep in mind that the condition of contribution does not apply to health insurance. Condition of contribution is a practice where if you have two policies insuring the same risk then the claim needs to be paid byboth the policies. But in the case of health insurance, if you have two policies, the insurers can’t insist that you use both to pay for the claim. You can choose the policy you want to use and if it’s not enough, move on to the next to pay the difference.
How to use two policies for the same claim?
When you use two policies to pay for a single claim, usually only one policy can be used in the cashless form. Suppose you need to pay Rs2 lakh for knee replacement, and you have an employer cover of Rs1 lakh and your own individual cover for another Rs1 lakh. Here, you would need to use both to pay the hospital.
When you approach a hospital, it will send your documents to one insurer for cashless approval. Once the insurer approves the amount, the hospital will ask you to pay the balance Rs1 lakh, which you will have to pay from your pocket at the time. On discharge, the insurer will send a settlement letter to the hospital mentioning the amount paid. You will need this settlement letter—ask the hospital or the insurer—to approach the second insurer. The settlement letter will have all the details such as thetreatment undertaken, amount paid, policy details and date of admission.
Usually, the settlement letter is enough to approach the second insurer for reimbursing the balance money you paid from your own pocket. You can also get additional documents from the cashless insurer, who will stamp the documents with the amount it has paid so far, so that there is no double payment.
However, if you have two policies from the same insurer, then a cashless payment on both is relatively easier to process.