4 min read

How To Make The Most Of Your Maternity Cover: The Story Of Rashi And Amar

A working couple, Rashi* and Amar*, have a maternity bill of INR 2 Lac. They have three healthy covers – two corporate policies and a personal health cover. Which policy(s) should they go for to claim the maximum amount?

Married for over five years and finally settled in their careers, Rashi* and Amar* decide to start their family. Rashi, a media professional at a growing start-up and Amar, a software developer at a large IT conglomerate, have ample health coverage, including maternity benefits with both their organisations covering their health and a personal health cover. Effectively, they have three health covers that very well can foot their hospital bill. 

In this case, let’s take a look at Rashi and Amar’s maternity covers:

Corporate Policy A**: 1 Lac INR Maternity Cover  

Corporate Policy B**: 1 Lac INR Maternity Cover  

Personal Policy C**: 50,000 INR Maternity Cover  

Total Coverage: 2.5 Lac INR

For Rashi and Amar, their corporate health insurance policies and personal health cover look well-suited to meet hospitalisation expenses for the birth of their baby. Given their present arrangement with the hospital, Rashi and Amar will have to tackle a hospital bill of 2 lac INR this September, after the delivery of their baby. . 

Maternity Cover: How it looks in action?

A look at maternity cover and benefits in action, and how room rent limits and proportionate deductions are critical to your claims process

Each of these policies comes with a slew of benefits and claims propositions. To their benefit, all three policies offer cashless reimbursement. The couple, depending upon their needs, can choose a policy to cover different aspects of the hospital bill–room rent, procedure, medicines, etc. The hospital bill lists the services they receive(such as procedures and tests), as well as medication and supplies. They will also get separate bills for health care provider fees.

Since all the policies offer cashless claims, the couple has to look at various other aspects and T&Cs of each policy. The finer print in maternity policies regarding room rent limits, network hospitals, proportionate deductions should be carefully read by the couple to assess which policy can give the maximum reimbursement or claim amount for the expenses. 

The * on Cashless Claims & Network Hospitals

An insurance provider has agreements with a few specific hospitals, which are referred to as Network hospitals. Some policies underline that the benefits of cashless claims can only be obtained by using the services of a network hospital. 

Suppose the couple decides to go for Policy A at a non-network hospital. Policy A which offers cashless claims only at network hospitals, would firmly reject any cashless claim request made. 

The couple decides to get admitted to any of the hospitals mentioned in the agreement (network hospital) of Policy A. They do not have to worry about managing the cash costs for their care because the insurance will bear the cost directly. There will be fewer hiccups since terms of filing and documents requirements would have POCs from the hospital and insurer interacting with each other to settle the hospital expenses. 

Room Rent Limit & Proportionate deduction

In most health insurance policies, if the room's rent taken by the insured exceeds the rent covered in the policy, then the hospital bill is not reimbursed whole. The insurer subjects the account to a 'proportionate deduction'.

Ultimately, which room the couple should go for depends on their needs. However, when they go for a room that costs INR 7000, the best way to recover cost is to get admitted in the room and use Policy A for room rent. The partial claim can then be recovered using policy B. costs.

Early discharge from the hospital, lengthier reimbursement process

While it is ideal that the couple book the hospital room and speak to their insurance POCs, it is possible that the couple has to rush to a hospital earlier than expected. In such a scenario, the couple would have to pay for hospitalisation expenses and apply for reimbursement for the claims amount. 

And if in this situation the couple decides to discharge from the hospital a day or so within childbirth, a number of procedural aberrations may plague the couple. 

The couple would have to inform the insurance company as per procedures required. After hospitalisation, they have to ensure that you obtain and keep documents ready–such as claim form, discharge summary, prescriptions and bills that they have to submit for a claim.

In all situations, it will be a lengthy process strewn with forms that need to be filled, bills that need to be submitted a certain way and varying TATs–and for three insurers in the couple’s situation. The couple will have to tackle mediations and proofs between different insurers bearing the cost of different items in the hospitalisation–room rent, healthcare provider fees, medicines and post-birth care. 

How the couple used their Maternity Cover?

Finally, the couple decides to use Corporate Policy A & Policy B to cover room rent and procedure costs respectively in the network hospital of Policy A. And in case either of the insurers reject claims for medicines and supplies, they go to their third insurer, Personal Policy C, to claim the payment for reimbursement. 

Policy Amount Room Rent
Cashless Reimbursement Amount claimed
Corporate Policy A 1 lac 5000 Total
Corporate Policy B 1 lac 7000 Total or Partial
Personal Policy C 50,000 Total or Partial

Making sure you get the most out of your Group Health Insurance policy

For most people, the claims process and the fine print in policies is a massive deterrent to 

Many couples are concerned about maternity bills as the cost of healthcare continues to skyrocket. Lack of knowledge and planning is at the root of much of the problem associated with health coverage. As a result, comprehensive maternity insurance as part of retail and corporate health insurance coverage should be a must when zeroing down on a policy. 

For a lot of couples, one of life's most wonderful experiences is becoming parents. One would like to be able to relax and enjoy the moments leading up to and following delivery. Even while maternity and related expenses are a normal part of life, it's best to prevent any surprise medical bills or underlying medical costs that aren't disclosed at the time of treatment.

*Names Changed for Privacy

**Policy Names hidden

DISCLAIMER- The information contained in this blog is provided solely for general interest and may not reflect the requirements of each individual/company. Please speak to an insurance expert before making any decision.

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