# Rs 25 lakh health cover, Rs 12 lakh bill, but insurer paid only Rs 5 lakh 2026-08-12T23:57:18+00:00 | Governance | Indian Opinion Desk Corroboration: 1 independent outlet A policyholder with Rs 25 lakh health cover faced a Rs 12 lakh hospital bill but received only Rs 5 lakh from the insurer. The insurer invoked the 'reasonable and customary charges' clause, which allows it to cap payments based on what similar hospitals in the area typically charge. Deductions included Rs 1.12 lakh on surgeon fees, Rs 76,570 on anaesthesia, and Rs 3.07 lakh on other charges. Business Today reports that there is no single regulatory price list for medical procedures, so prices vary widely. Insurers use this clause to limit what they consider irrational hospital pricing. Experts say policyholders should ask for a clear breakdown of deductions, choose insurers with good claim-settlement records, and understand this clause before buying a policy. A high sum insured does not guarantee full payout. ## Coverage - businesstoday.in Tags: claim settlement, health insurance, IRDAI, policyholder rights, reasonable and customary charges Canonical: https://indianopinion.org/rs-25-lakh-health-cover-rs-12-lakh-bill-but-insurer-paid-only-rs-5-lakh/ License: Summary and commentary (c) Indian Opinion, reusable with attribution. Facts belong to the linked sources. Cite: https://indianopinion.org/rs-25-lakh-health-cover-rs-12-lakh-bill-but-insurer-paid-only-rs-5-lakh/#story-in-brief Review state: restored archive article, accurate at time of publication, not offered to search indexes.