My insurer cut the whole hospital bill because my room cost more than the limit. Can it?
Many health policies cap room rent and, when you take a costlier room, reduce other charges in the same proportion. IRDAI does not ban this. It requires the policy schedule to state the sub-limits and proportionate deductions, with a cross-reference to the policy section (Master Circular on Protection of Policyholders' Interests, Schedule C para 3.1(ix)). The Customer Information Sheet you got at purchase lists the room and ICU limits too.
The same circular bars any deduction from a claim in the name of an exclusion the policy does not list (Chapter IV, para 16.3), and any rejection has to cite the policy term (Health Master Circular, para 17). So the test for your claim is whether the deduction your insurer applied appears in your policy wording, in the form it was applied.
Many guides say proportionate deduction cannot touch ICU charges, or hospitals that bill every room the same. We did not find that rule in IRDAI's current regulations or master circulars, so read your own policy wording on those charges before relying on it.
A partial cut counts as a partial repudiation, which the Insurance Ombudsman hears. Complain to the insurer first, which has 14 days to resolve it, then go to the Ombudsman within one year.
If this is where you are
The insurer rejected my claim and quoted a clause. I need to answer it in writing before I can go to the ombudsman.
Appeal letter against a rejected insurance claim
A complaint letter to the insurer's grievance officer, with your policy clause and their reason set out, and a sheet with the dates that follow.
₹299₹499
Launch price until 30 November
Common questions
Where do I find my room-rent limit?
In the policy schedule, and in the Customer Information Sheet under the financial limits of coverage.
Can the insurer cut charges for a reason the policy does not mention?
No. The policyholder master circular says no further deductions shall be made in the name of any other exclusions.
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