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Why Insurers May Not Pay The Claims Against Medical Bills In Full?

Updated On Jul 30, 2021

Health insurance policies are bought to financially support the policyholders against the medical expenses incurred in case of an emergency. If the coverage under the policy is insufficient then the customer has to pay the medical dues from their pocket, which can eventually stress their finances and saving amounts. Apart from the insufficiency of the coverage amount, there are several other reasons for the insurer to not pay the complete claim amount to the policyholders. 

You must be aware of the terms and conditions of your purchased health insurance policy to avoid any confusion at the time of claim settlement of the policy. If you request a claim for a condition which has been excluded by the health insurance provider, then your claim request will be denied by the insurance company. The company offers a period of 15 days as a free-look period to the policyholders after the purchase of their policy to let the customers go through the policy-related documents and request changes if any. 

Why Insurers May Not Pay The Claims Against Medical Bills In Full?

Reasons Why Insurers May Not Pay The Claims Against Medical Bills In Full?

There can be a situation where an insurance company might deny your claim request or in case of acceptance it might not pay the full amount of your medical dues. This condition can arise due to several reasons, some of which are as follows: 

1. Consumables 

3 to 6% of hospital bills are consumed by the consumables. If a policy does not include to cover the consumables then the policyholder has to bear the medical bills out of their pocket. 

2. Expense Limitations

Some health insurance policies come with limitations on the medical expenses and other medical charges. The properties of this feature should be checked properly while buying a health insurance cover.

3. Procedure Sub-Limits 

Some treatments cost more than the sum assured under the policy cover.Therefore in cases where the medical dues exceed the limit of the sum assured, the policyholder has to pay the difference in amount from their pocket. This can happen if you claim a standard health insurance policy for the treatment of hernias, cataracts, etc. 

4. Policy Sub-Limits

Under certain health insurance policies, there are limits imposed on some specific benefits like AYUSH treatment. Like for pre and post hospitalization expenses, around 10% of the inpatient claim is capped by the insurer. Therefore, to avoid any last minute inconveniences during the claim settlement process, you must thoroughly read all the sub-limit clauses in the document.

5. Geographical Restrictions

The premium of your health insurance policy depends on the geographical area that you live in. People living in metro cities have to pay a larger sum of premium than people living in small towns due to the difference in the cost of treatment. Therefore, if you receive treatment in a metro city, then the exceeding amount on your medical bills has to be borne by you from your savings. 

6. Restrictions On Room Rent 

You must make sure that your health insurance policy does not come with a very low room rent limit. Due to the lower limit of room rent, there can be non-settlement of the entire claim amount of your health insurance policy. To avoid any inconvenience during hospitalization, you must have a sound idea of the restrictions on room rents and room rent categories. Based on your sum assured and the choice of hospital, you might end up paying the high amount of room rent from your pocket thus bearing the costs. 

7. Co-Payment 

Availing of the services under your health insurance policy depends on the co-payment clause of your policy, as it mentions the cost-sharing provisions for the policyholder. Make sure that you buy a health insurance cover with a smaller  percentage of co-payment as a higher percentage of co-payment can result in the draining of your financial savings. 


The restrictions in your claim settlement process can arise due to the above-mentioned reasons and therefore, you must carefully read the fine print of your policy to thoroughly understand the terms and conditions. 

Also Read: Top Up health Insurance and Mediclaim Policy Cover

Mediclaim Insurance Policy: Tips to File Reimbursement Claims

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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