Health Claim Short-Settled? Recover Unfair Deductions

Claim paid less than your hospital bill?

In short: A short-settled claim is one where the insurer paid only part of the bill. Ask for the item-wise breakup of deductions, check each one against your policy, and challenge the ones the policy does not support. For example, proportionate deductions for a higher room cannot be applied to medicines, consumables, implants or diagnostic tests.

The deductions we see most

Room rent and proportionate deduction. If your policy allows a room of ₹5,000 a day and you stayed in one costing ₹10,000, the insurer may cut many related charges, such as doctor visits, in the same proportion. IRDAI rules do not allow this cut on pharmacy, consumables, implants, medical devices or diagnostics, or in hospitals that charge the same for every room category.
Non-payable items. IRDAI has a standard list of items that are not payable, such as gloves and masks, unless your policy has a consumables cover.
Co-payment. Some policies make you pay a fixed share of every claim, often on senior citizen plans.
Sub-limits. Some treatments, such as cataract surgery, have a fixed maximum regardless of the bill.
“Reasonable and customary” charges. The insurer says the hospital charged more than usual for a procedure.
Bills left out. Pre- and post-hospitalisation bills that were never counted.

What to do, step by step

Get the breakup. Ask the insurer or TPA for the settlement letter with every deduction listed item by item.
Match each deduction to a clause. If the letter does not name the clause, ask which one it relies on.
Check proportionate deductions. Make sure they were not applied to medicines, consumables, implants, devices or tests.
Write to the grievance cell. List each disputed deduction with the amount and the reason it is wrong.
Escalate. If the insurer does not correct it, go to Bima Bharosa and the Insurance Ombudsman.

How Mediclaimswala helps

We go through the bill and the settlement letter line by line, separate the deductions your policy allows from the ones it does not, and claim back the difference in writing.

Last reviewed: 15 November 2026. This page is general information based on IRDAI rules as of the date above. It is not legal advice. Policy wordings differ, so we check what applies to your case.

Questions people ask

What is a proportionate deduction?

When you stay in a room costlier than your policy allows, the insurer may reduce related charges, such as doctor fees and nursing, by the same proportion. It cannot be applied to medicines, consumables, implants, medical devices or diagnostic tests.

Are consumables like gloves and masks covered?

Usually not. IRDAI has a standard list of non-payable items. They are paid only if your policy includes a consumables cover.

I have already received the reduced amount. Can I still dispute it?

Yes. You can raise a grievance about the amount that was deducted. If the insurer does not resolve it, you have a year from its reply to approach the Insurance Ombudsman.

How do I know which deductions are fair?

Compare each deduction with your policy schedule and wording. Room-rent limits, co-payment and sub-limits are written there. Deductions with no clause behind them are the ones to challenge.