Your claim was settled in part, with deductions
How to read a settlement statement, how to ask for a line-by-line breakup, and which deductions are worth taking up.
What this situation means
A partial settlement means the insurer has accepted the claim but paid less than the amount claimed. The difference is made up of deductions, and each deduction should have its own reason.
Deductions usually fall into a few groups. Some items are excluded by the policy wording — consumables and certain non-medical items are the usual example. Some are limited by a sub-limit, such as a cap on room rent or on a particular procedure. Some follow proportionate deduction, where choosing a room above your eligible category reduces associated charges. Some are simply items the insurer says are not payable on these papers.
The reason matters, because the answer is different in each case. A sub-limit written into your policy is a term of the contract. A deduction applied without a stated reason is something you can ask about.
What to check first
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The arithmetic
Claimed amount, approved amount, and the difference. Write the three numbers down before anything else.
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Whether a breakup was given
A settlement letter often shows a total deduction without a line-wise working. If so, that is the first thing to ask for.
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Your room category
Check the room rent limit or category in your policy schedule against the room you actually occupied. This one item explains a large share of deductions.
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Non-medical items
Insurers usually apply a standard list of non-payable items. Compare the deducted items against the itemised hospital bill.
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Sub-limits and co-payment
Read the schedule for any per-procedure limit, disease-wise cap or co-payment percentage that applies to your policy.
What to keep
- The settlement letter or payment advice showing the amount approved
- The itemised final hospital bill, not just the summary bill
- The policy schedule showing room rent limits, sub-limits and co-payment
- The pre-authorisation papers, if the treatment was cashless
- Pharmacy and implant invoices, where they form part of the claim
- The complete email thread with the insurer or TPA
How to write to your insurer
- Ask for a line-wise breakup of the deductions, stating against each item the specific clause of the policy or the reason relied upon. This one request often resolves the confusion by itself.
- Keep the claim number in the subject line and reply on the existing thread.
- Deal with the deductions one at a time. Accepting the ones that are clearly within the policy makes the remaining points easier to discuss.
- Where an item appears to have been deducted twice, or deducted although it is not on the insurer's own non-payable list, point to the bill line and the clause.
- Ask for the revised working, if any, to be confirmed in writing.
A written record helps you keep track of what was asked, what you submitted and what was communicated. The claim guide has the email templates.
How ClaimSaathi can help
We can help you read the settlement working against your policy schedule and the itemised bill, prepare a clear request for a line-wise breakup, and prepare a response on the items that appear worth taking up. We do not promise that any deduction will be reversed.
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