Health Insurance Claim Calculator (India): Room Rent and Co-pay

About the Health Insurance Claim Calculator (India): Room Rent and Co-pay

A health policy rarely pays the whole hospital bill. A room above your room-rent limit costs you the difference — and, under a proportionate-deduction clause, a matching share of the doctors’ and theatre charges too. Co-payment, a deductible, a sub-limit for the treatment and the items no policy pays (gloves, attendant charges, admission kits) take more off.

Enter the terms from your policy schedule and Customer Information Sheet and the bill by head. By default the calculator follows the norms IRDAI set for proportionate deduction — never on medicines, consumables, implants or diagnostics, never on ICU charges, and not at all where the hospital charges the same whatever the room — and you can change each part to match your policy wording. It removes the items in IRDAI’s lists unless your policy covers them, and shows the payout and your share line by line. Run a second policy on the same bill to compare, or to see what it can add. Nothing you enter leaves your browser.

Common uses

• Check before a planned admission which room keeps your claim whole.
• Understand a settlement letter that paid less than the bill.
• Compare your own policy with your employer’s group cover on the same bill.
• See how much a co-payment, deductible or sub-limit really costs on a large bill.

How the payout is worked out

• Room and ICU: paid up to the limit a day — a fixed amount, or a percentage of the sum insured with its cap. The rest is yours.
• Proportionate deduction: when the room is above the limit, the policy pays the same share of its associated medical expenses: eligible room rent ÷ actual room rent. A ₹5,000 limit on an ₹8,000 room pays 62.5% of those charges.
• Items not payable come off next, then any sub-limit for the treatment caps the claim.
• Deductible and co-payment: the deductible is “a specified amount stated in the policy up to which an insurer will not pay any claim”, the co-payment “a specified amount / percentage of the admissible claim amount to be paid by policyholder” (IRDAI health insurance FAQs). The calculator takes the deductible off first, then the co-payment on the rest; switch the order if your policy says so.
• Cover left: sum insured + cumulative bonus − what you have already claimed this policy year + any restored sum insured. The payout never exceeds it.

What IRDAI’s norms say about proportionate deduction

IRDAI’s norms on proportionate deductions told insurers to define the associated medical expenses in the policy, and did not allow that definition to include:

• the cost of pharmacy and consumables;
• the cost of implants and medical devices;
• the cost of diagnostics.

They also said proportionate deductions are not applied where the hospital does not follow differential billing (it charges the same whatever the room), or to expenses not billed by room category, and not to ICU charges, “as different categories of ICU are not there”.

Policy wordings written to those norms carry this clause. IRDAI’s later Master Circular on Health Insurance Business repealed the circular, so read the proportionate-deduction clause in your own policy: the calculator follows the norms by default and lets you change each part under Proportionate deduction.

Items IRDAI lists as not paid separately

IRDAI’s guidelines on standardisation in health insurance sort the small items on a hospital bill into four lists, which the standard Arogya Sanjeevani policy annexes too:

• List I — optional items (68, such as gloves, masks, nebulisation kits, attendant charges, diapers, telephone and laundry): not paid unless the policy offers cover for them, for example through a consumables add-on;
• List II (37, such as admission kits, gowns, housekeeping, documentation charges): part of the room charges;
• List III (23, such as gauze, surgical blades, drapes): part of the procedure charges;
• List IV (18, such as admission and registration charges, infusion pumps, diet charges): part of the cost of treatment.

The guidelines ask insurers to make sure network hospitals do not bill List II–IV items to policyholders in cashless claims: if they appear on your bill separately, ask the hospital’s insurance desk.

IRDAI’s standard policy: Arogya Sanjeevani

General and standalone health insurers that sell indemnity health cover must all offer the same standard policy, Arogya Sanjeevani. Its limits (IRDAI FAQs): room, boarding and nursing up to 2% of the sum insured, at most ₹5,000 a day; ICU up to 5%, at most ₹10,000 a day; a 5% co-payment on every claim; cataract up to 25% of the sum insured or ₹40,000 per eye, whichever is lower; road ambulance up to ₹2,000 a hospitalisation; and a cumulative bonus of 5% a claim-free year, up to 50%. The FAQs add that a room, ICU or ICCU rent above these limits makes the claim subject to proportionate deduction, while IRDAI’s norms on proportionate deductions ruled it out for ICU charges. The preset fills in the limits and follows the norms: tick Also cut in proportion when the ICU is above its limit if your insurer’s wording applies it to the ICU.

Two policies on one bill

With two indemnity policies — say your own and your employer’s group cover — you choose which to claim from. If its cover is less than the admissible claim, that insurer coordinates with the other to settle the balance as per the policy conditions (IRDAI’s Master Circular on Health Insurance Business, Chapter I). Tick Compare a second policy: the calculator runs both on the same bill and shows the most the second policy can add after the first.

If the claim is cut more than you expected

Ask the insurer for the settlement letter: when a claim is disallowed in part, the insurer has to give “full details giving reference to the specific terms and conditions of the policy document” (Master Circular on Health Insurance Business, Chapter I). Compare it with this estimate line by line. If you still disagree, complain to the insurer’s grievance officer, then through IRDAI’s Bima Bharosa portal; after that you can go to the Insurance Ombudsman — the ombudsman complaint generator drafts the complaint.

Limitations

• An estimate under the terms you enter: the insurer’s settlement letter decides. Waiting periods, exclusions, pre-existing diseases and the policy’s other conditions are not checked.
• Package rates: many hospitals bill a procedure as a package. Enter it under the theatre and procedure charges; whether a package is cut in proportion depends on your policy and the hospital’s tariff.
• A limit set as a room category (“single private room”) pays that category’s rate at your hospital: ask the hospital for it and enter it as the limit a day.
• Pre- and post-hospitalisation expenses are taken as you enter them; enter only those inside your policy’s days.
• Cash allowances, OPD cover and benefit (fixed-sum) policies are not covered.

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