The recently announced govt scheme for those aged 70 and above (Ayushman Bharat PM JAY) is applicable to us also, although we are covered by Group Mediclaim Insurance taken by LIC. When an insured member is covered by multiple policies, there can be only one claim, as it is an indemnity insurance unlike life insurance.
The situation for an individual to have multiple insurance covers is rare hitherto. The claim form always seeks information from claimant as to whether he holds any other medical insurance. The answer has always been: "No" Mostly (but not always) it is a fact.
New situation:
What will be the covered benefits and conditions under PMJAY, is sill not known. Presuming the situation that both are mostly identical and we have the option to claim from our group scheme or govt scheme, the usual "No" answer is not possible. Therefore. question arises as to how claim will be settled.
In general insurance inclusive of medical cover, sharing of the medical claim (for that matter, any loss) by two or more insurers ALWAYS operates. It is NOT by equal sharing but by a formula, termed as 'rateable proportion' (details skipped).
I raised a query to a recently retired CMD of a General Insurance, and he in turn passed on the query to a current GM. The query and response are as below:
Query: "He is retired from LIC. 70 and 70+ are eligible for health insurance coverage. He is covered by group insurance like us. That means for claim, if any, will be settled in rateable proportion? What is the actual position?"
Reply: "Yes Sir, but it's only a declaration at the moment and yet to be implemented. Then they have Ayushman Bharat in the empanelled hospital and for agreed packages."
Matter is hazy as it is. Hope, the operation of both the schemes will be made simple.
M. Arunachalam
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