When you submit a health insurance claim, the insurer may not approve the full amount. The difference between the amount you claim and what is paid is called a deduction.
Claimed Amount – Approved Amount = Deduction
These deductions are based on your policy terms and conditions, and they help ensure that the insurer only pays for items and treatments that are covered.
Certain items are not covered under most health insurance policies as per IRDAI and insurer guidelines. Examples include:
Gloves, cotton, tissues, bandages
Registration fees
Syringes, masks, personal protective items
Your policy may limit the room rent per day (e.g., ₹3,000/day). If you stay in a higher category room, a proportionate deduction is applied to the entire bill — not just the room charges.
Example: Room rent allowed: ₹3,000/day
Actual room used: ₹6,000/day
So, all other charges (doctor fees, surgery, nursing) may be reimbursed at 50%.
Some policies have fixed maximum limits for specific procedures, like:
Cataract: ₹25,000 – ₹50,000
Hernia: ₹60,000
Even if the hospital charges more, the insurer pays only up to the sub-limit.
If your treatment involves a condition or service excluded under your policy, it won’t be covered. Common exclusions include:
Cosmetic surgeries
Dental treatments (non-accidental)
Pre-existing conditions within waiting period
Some policies (especially for senior citizens) include a co-payment—where you agree to pay a fixed % of the total bill.
For example: 20% co-pay on a ₹1,00,000 bill = ₹20,000 paid by you.
Missing documents like:
Original bills
Prescriptions
Investigation reports can lead to partial claim rejection or deductions.
| Reason | Amount Deducted | Explanation |
|---|---|---|
| Room Rent Capping | ₹10,000 | Room rent exceeded policy limit |
| Non-payable Consumables | ₹2,500 | Cotton, gloves, sanitizer not covered |
| Sub-limit on Cataract Surgery | ₹15,000 | Claimed ₹60,000; capped at ₹45,000 |
| Co-payment (10%) | ₹8,000 | Policy includes 10% co-pay clause |
| Missing Investigation Report | ₹5,000 | Lab report not submitted |
