How Many Times Can You File a Health Insurance Claim?

The question of how many times can we claim health insurance is quite common and an important one. The simple answer is that an individual can make multiple claims in a year. You can raise claims until the sum insured is exhausted. However, this may not be the ideal way to go, as not having health insurance coverage means you may have to pay for medical expenses out of your pocket.
Some health insurance policies offer a restoration benefit. It enables you to restore the sum insured if you have exhausted the coverage amount.
 

Understanding when you can raise a health insurance claim is essential to avoid confusion during medical emergencies. The following is some information about timelines, waiting periods and exceptions:

• Claim Submission Timeline

The timeline for claiming a health insurance policy depends on your policy. It may also depend on the type of medical service you or your family member is utilising. Most policies allow you to raise a claim within a specified time frame. On failing to submit the claim within the specified time frame, your claim can be denied.

• Initial Waiting Period

The question of how many days after enrolment we can claim health insurance is common. This is because there is usually an initial waiting period at the start of the policy. As per the Insurance Regulatory and Development Authority of India (IRDAI), after you start a policy, you must wait for 30 days from the start date before raising claims. However, it is important to note that waiting periods can vary by policy/product type.

• Exception for Accidents

The initial waiting period does not apply to accidental hospitalisation. Claims arising from accidents can typically be made immediately upon the policy's inception.

Health insurance premiums may not increase immediately after claims but can be affected during renewal based on claim history and underwriting policies.

It is also important to remember that the health insurance premium is also determined by a policyholder’s age and the plan that they have selected. Premium revisions, if any, are generally based on factors such as age, policy terms, claim history, and underwriting considerations.

For consistent financial planning, it is important to understand family floater coverage: how many claims can be made, how they are managed and what benefits families may receive. The following pointers offer such information:

• How Family Members Share Sum Insured

In family floater plans, the health insurance is shared among all family members under a single sum insured. These plans can cover the spouse, children and at times, parents. Claims can be made by any of these family members till the sum insured is exhausted.

Typically, there is no limit on the number of claims you can raise per year. The only rule applicable may be that the total pay-out must not exceed the sum insured.

• Restoration Benefit in Floater Plans

The restoration benefit plays an important role in family floater plans. In such plans, there is a high possibility that the entire sum insured will be exhausted among family members.  With this benefit, depending on the policy terms, the sum insured may be restored after partial or complete utilisation.

• Managing Claims for Multiple Members

Managing claims can be simplified by following simple tips. For instance, individuals can choose a higher sum insured to help avoid exhaustion. It is important to ensure timely health insurance renewal to maintain coverage continuity. Getting well-acquainted with policy limits can help prevent benefit restrictions.

The No Claim Bonus (NCB) is a reward for maintaining a claim-free year. It can reduce or reset if a claim is filed within the policy year. Most insurers follow a straightforward rule: any claim, big or small, can affect the collected NCB. Maintaining a claim-free year can help policyholders retain this benefit.

A health insurance plan offered by SBI General Insurance can also have a cumulative benefit. This means the sum insured or coverage amount will increase for each claim-free year. The premium amount will remain the same. Over time, this can significantly boost your health insurance coverage.

Additional health insurance claims are often rejected owing to the following reasons:

• Waiting Period Not Completed

Many policies have a waiting period for specific diseases or pre-existing conditions. Filing a claim before this waiting period ends may result in claim rejection.

• Sum Insured Fully Exhausted

The total sum insured may be utilised fully through multiple claims in a year. This can lead to the rejection of further claims.

• Exclusions and Policy Limitations

Most policies mention certain treatments or procedures that are not covered or have limited coverage. If these limitations and exclusions are overlooked when filing claims, they may result in rejection.

• Incorrect Claim Documentation

At times, documents like bills or diagnostic reports are not provided. Individuals may also make mistakes during documentation. These factors can lead to rejection.

Health insurance claims can be filed until the sum insured is exhausted. Understanding factors such as waiting periods, restoration benefits, and policy terms can make the claim process smoother. Understanding exclusions, documentation, and timelines helps individuals reduce claim rejections and utilise their health insurance coverage accurately. 

With a range of health insurance solutions, SBI General Insurance offers coverage options designed to support different healthcare and financial needs.

1. Can I file a health insurance claim for both planned and emergency hospitalisation?

Yes, you can file claims for both planned and emergency hospitalisation. However, they must be covered under the policy.

2. Does making frequent health insurance claims affect policy renewal?

Frequent claims do not prevent renewal but may affect benefits such as the No Claim Bonus and sometimes influence premium adjustments.

3. Can I claim health insurance for OPD treatments multiple times in a year?

If OPD expenses are covered under the policy, multiple claims can be made in a year. However, the policy limits must be adhered to.

4. Is there a waiting period before filing a second health insurance claim?

There is usually no gap between claims, provided the condition is covered and waiting periods are already completed

5. Can I file separate claims for pre- and post-hospitalisation expenses?

Yes, these are usually covered under a single treatment claim, subject to policy limits.

6. Do daycare procedures count as separate health insurance claims?

Yes, daycare treatments are treated as individual claims if covered under the policy.

7. Can I claim from two health insurance policies for the same treatment?

Yes, you can claim from multiple insurers, but the total reimbursement cannot exceed the actual treatment cost.