The fundamental reason to buy a health insurance policy is to avoid hefty medical bills. However, some cost related to medical bills still has to be borne by the policyholder even when carrying a cashless health card and availing services of a network hospital. Let us understand why your claim may get paid partially even if you have a comprehensive health insurance policy.

This may happen when the claim is made for medical expenses that do not constitute a part of the coverage of a health insurance plan. It may also happen if the insurance provider deems the incurred medical expenses as unnecessary for the necessary treatment of the insured. Insurance companies only settle claims for those expenses which are mentioned under the coverage/inclusions in the policy document shared with the insured at the time of policy purchase.

Most of the time, deductions in claims are due to factors mentioned below:

1. Non-Medical expenses: Administrative charges, registration charges, surcharges, food apart from patient’s nutrition, consumables, etc., may not be covered under the health policy.

2. Charges: Investigation charges/expense that is not related to the ailment you are getting admitted may not be paid by the insurer. For instance, if admission is for say, pneumonia, then MRI of the spine may not be paid since it is not related to the treatment of Pneumonia.

3. Room rent eligibility: This is the essential criterion for getting the maximum out of your claim. Most of the policies have room rent defined. Suppose one gets themselves admitted to a room higher than the eligibility. In that case, they are bound to have significant deductions as expense heads like doctor charges, investigation charges, OT charges vary based on the room category you opt for.

4. Consumables: Most health insurance policy typically does not cover the cost of most consumables used to treat diseases in a hospital. The out-of-pocket expenses, which are not considered in the claims, are consumables, medicines (non-ailment), wearables, copayments, or copays. This percentage of the claim amount has to be borne by the policyholder. It may be on medical bills, hospitalizations, or senior citizen policies. Deductible amounts range greatly based on coverage, location, and more. Therefore, this is something that the insured ends up paying from their pocket.

Hence, one should always read the policy document clearly and clarify the doubts, if any, with the insurance provider/broker to avoid such gaps in understanding at the time of a claim settlement.