Can You Claim For A Second Hospitalisation In The Same Year?

A second hospitalisation in the same policy year does not mean that the full bill will be paid. The insurer checks how much of the sum insured remains after settling the first claim. If the balance is not enough, the policyholder may have to pay the difference.

“If the insurer pays Rs 3 lakh for the first hospitalisation, the remaining base cover is generally Rs 2 lakh. The calculation is based on the admissible amount paid by the insurer, not necessarily the hospital’s total bill,” says Sarita Joshi, head of life & health insurance, Probus.

For example, if a policy has a sum insured of Rs 5 lakh and the insurer pays Rs 3 lakh for the first hospitalisation, the base cover left would generally be Rs 2 lakh. If a second admissible claim is Rs 3 lakh, the remaining cover may fall short by Rs 1 lakh. The policyholder would need to pay the gap, apart from expenses not covered under the policy.

The balance depends on the amount the insurer pays after applying any co-pay, deductible, or policy limit. Your policy may also add a cumulative bonus to your cover.

When Does Your Policy Refill The Cover?

A restoration benefit can top up health insurance cover after some or all of the sum insured has been used. Policies differ on when the benefit kicks in. Some require the base sum insured and any cumulative bonus to be exhausted, while others may allow restoration after partial use. A policy may also limit how many times cover can be restored in a year and the amount added back.

The benefit may be intended for a later hospitalisation in the same policy year. But policyholders should not assume it will apply to every second claim. Check the trigger, whether restoration is allowed after partial use, how many resets are permitted, and the maximum amount that can be restored. Find out whether unused restored cover lapses at renewal.

Check The Same Person And Illness Rules

A restored amount may be used for the same insured person, but that does not guarantee payment for a second admission for the same illness. Some policies allow the refill for the same person only if the later hospitalisation is for an unrelated condition. Others may cover a repeat admission for the same illness, sometimes after a specified gap. Check the policy wording before relying on restoration for a recurring condition.

“Others may permit a repeat admission for the same condition, sometimes after a specified gap. For instance, a person treated for a heart condition may find that another admission for it is restricted, even when restoration is available,” says Joshi.

Check the restoration clause for the number of resets, the amount restored, and whether the benefit applies to each insured member under a family floater. If the wording is unclear, ask the insurer to explain it in writing.

These details determine whether a second hospitalisation is covered by remaining cover, restored cover, or the policyholder’s own funds.

FAQs

Does health insurance cover a second hospitalisation in the same policy year?
It may, up to the sum insured left after the first claim. Co-payments, deductibles, policy limits and exclusions can affect the amount payable.

Can a restoration benefit pay for a second hospitalisation?
It depends on the policy’s trigger, restoration limit and number of permitted resets. Some policies require the base cover to be exhausted; others allow restoration after partial use.

Can restored cover be used for the same person or illness?
Some policies allow it for the same person, but may restrict repeat admissions for the same illness or require a gap between admissions. Check the policy wording.