Health claim only partly paid?

Every deduction needs a clause

A partial disallowance must be communicated with full details, referring to the specific terms and conditions of the policy. The policy must clearly state its exclusions, sub-limits, co-payment and proportionate deductions. Where the policy document and the customer information sheet conflict, the policy document prevails.

Common deductions and how to test them

• Non-payable items and consumables (gloves, masks, kits): IRDAI’s standard list was repealed in 2024, so this is now down to your policy’s own list. Insurers must put their list of non-covered items in the policy and on their website. A consumables add-on pays what its wording says.
• “Reasonable and customary” cuts: most wordings define these as the standard charges of the specific hospital, consistent with prevailing charges in the area. Ask what the insurer compared your bill with.
• Co-payment: it must be written in your policy schedule. If it isn’t, there is no basis for it.
• Sub-limits and room rent: these must be stated in the policy. See our guide on room-rent cuts for proportionate deductions.

Ask for the settlement sheet

Ask the insurer or TPA for the itemised claim settlement sheet. It should show each amount marked payable, not payable, co-pay or sub-limit, each with the policy clause behind it. Ombudsman offices have asked TPAs to prepare sheets in exactly this form.

What to do

1. Get the full policy wording, your policy schedule and the itemised settlement sheet.
2. Mark each deduction that the wording doesn’t support, or that cites no clause.
3. Write to the Grievance Redressal Officer with the list. If you’re not satisfied, a partial repudiation is a ground for an Insurance Ombudsman complaint.