Now Reading: Rs 25 lakh health cover, Rs 12 lakh bill, but insurer paid only Rs 5 lakh
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Rs 25 lakh health cover, Rs 12 lakh bill, but insurer paid only Rs 5 lakh
Rs 25 lakh health cover, Rs 12 lakh bill, but insurer paid only Rs 5 lakh
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'…
The Story in Brief
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.
The Indian Opinion
The 'reasonable and customary charges' clause is not a scam but a shield against hospital overcharging. Yet insurers use it opaquely, leaving policyholders shocked. The real test is transparency: will insurers disclose benchmarks upfront when a policy is sold? Or will it stay a fine-print trap? A clear regulatory mandate on how these charges are calculated would settle the debate.
Source: businesstoday.in
This story was synthesised by AI from the source linked above.
