Pre and Post Claim Process

1. Non-payable Items

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

2. Room Rent Capping

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%.

3. Sub-limits on Treatments

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.

4. Policy Exclusions

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

5. Co-payment Clause

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.

6. Insufficient or Incomplete Documentation

Missing documents like:

• Original bills

• Prescriptions

• Investigation reports can lead to partial claim rejection or deductions.