Answer Book question
Because health policies pay eligible expenses within the policy's rules, not the bill as presented. The usual reasons, in order of frequency: non-payable consumables, room-rent proportionate deduction, co-pay, sub-limits on the procedure, and anything the insurer considered not medically necessary. Ask for the itemised settlement letter; it lists each deduction.
Because health policies pay eligible expenses within the policy's rules, not the bill as presented. The usual reasons, in order of frequency: non-payable consumables, room-rent proportionate deduction, co-pay, sub-limits on the procedure, and anything the insurer considered not medically necessary. Ask for the itemised settlement letter; it lists each deduction.
Bill ₹6.2 lakh, insurer paid ₹4.1 lakh. The settlement letter shows: ₹41,000 non-payables, ₹92,000 proportionate deduction because the patient took a ₹9,000/night room against a ₹5,000 cap, ₹62,000 co-pay at 15 percent, and ₹15,000 for a diagnostic the insurer deemed unrelated.
Every policy has an annexure of standard non-payable items (IRDAI has a standard list). Room-rent caps apply proportionately to most charges, not only the room. Co-pay is a fixed share you bear. Sub-limits cap specific treatments. Medical necessity disputes are the only truly contestable category.
The itemised settlement letter from the insurer Room category vs. policy cap Co-pay percentage Sub-limit on that procedure Which items were marked non-payable
The room choice is the single most expensive mistake. A room one category above the cap can reduce the payout on surgery and doctor fees by the same proportion. Choose the room that matches the policy, or upgrade knowing the arithmetic.
Private rooms in Kerala's urban hospitals frequently exceed older policies' caps of ₹3,000–5,000/night. Check the cap before admission.
Bill ₹6.2 lakh: after all deductions, paid ₹4.1 lakh. If the patient had taken the ₹5,000 room, the proportionate deduction of ₹92,000 would have been zero and payout would have been about ₹5 lakh.
If the deduction is for "not medically necessary" and your doctor disagrees, that is worth contesting with a doctor's letter. Non-payables and room deductions are generally not contestable.
Get the itemised settlement letter Match each deduction against your policy wording Contest only medical-necessity items, with a doctor's letter
What is room-rent capping? What does 20% co-pay mean? My health claim was rejected. What should I ask for in writing?
Health, disability & life events
IRDAI health insurance regulations and consumer guidance · Your policy wording and schedule · Karunya Arogya Suraksha Padhathi (KASP) / PM-JAY guidelines for whether you may qualify Rates, limits and whether you may qualify change. Confirm with the official source. Ask Kerala Rising: Send us the policy schedule and the ages of everyone covered. We will tell you what the policy actually pays, what it does not, and whether a large bill would be survivable. WhatsApp +1 443 595 9000 · keralarising.com Kerala Rising › Money › Health insurance · Health 7
This page is general orientation, not personal insurance, investment, medical, legal, lending, tax, or professional advice. Rules, rates, benefits, and claim or application decisions can change. Confirm the current position with the named official source and use a licensed or qualified professional where your situation requires one. Kerala Rising does not decide whether you may qualify, approve claims, or promise an outcome.