Somewhere in Mumbai, Ananya sat
at her dining table with a hospital bill in front of her and the post-surgery
ache in her side. The surgery had gone well. The insurer had “approved” her
claim. The hospital had discharged her smoothly.
Everything should have been fine.
Except it wasn’t.
Her approved claim of ₹1,38,000
had magically shrunk to ₹1,09,400.
A
neat little line item stared back at her:
“Non-payable consumables – ₹28,600.”
No explanation.
No breakdown.
Just a quiet assumption that she
would accept this, as most people do.
But Ananya did something
unusual that day: she paused. She wondered, “Should
something essential to my treatment be considered ‘non-payable’?”
Most policyholders never even ask
that question. Yet that question is where every unfair short settlement begins
to crumble.
1. The Truth Behind ‘Non-Payable’
That Nobody Tells You
So you get deductions like:
● ₹1,850
— “gloves”
● ₹950
— “cotton rolls”
● ₹2,200
— “syringes”
● ₹3,000
— “room consumables”
Sounds tiny, right? Until you
realise these “tiny deductions” become ₹12,000–₹35,000 losses per claim.
Usually, these out-of-pocket
costs make up about 5–10% of the medical bill. (mint, 2022.)
When talking numbers, for a bill
around ₹5 lakh, this might be between ₹25,000 and ₹50,000.
Many short settlements occur not
because the insurer is acting maliciously. On the contrary, it was intended to
benefit both sides; policyholders aren't left wondering what won't be covered
while also being protected from unjustified exclusions, and insurers have a
consistent point of reference.
Moreover, following the COVID-19 pandemic, a lot of health
plans now include "consumables/non medical expense cover" that covers
the price of certain items (PPE kits, gloves, syringes etc.)
2. The Myth That Makes Everyone
Give Up
Hospitals follow a billing
structure. Insurers follow a claims policy. And both rely on a third layer —
the internal non-payable list created
as per IRDAI guidelines and product-specific terms. But here’s the expertly
verified truth:
Short
settlements are NOT final. They are
highly contestable.
You can—and absolutely
should—contest:
● Items
essential to surgery or treatment
● Incorrectly
coded items
● Consumables
medically required
● Items
misinterpreted by TPA software
● Any
deduction without a clause-based explanation
Many deductions are legitimate.
But many are simply the result of:
– poor
coding
– misunderstandings
of policy wording
– hospitals
adding misc. consumables
– insurers
applying standard lists instead of plan-specific terms
If your Claimsettlement is unexpectedly low, and you see unexplained consumable
deductions, you have every right to question, analyse, and contest them.
3. Ananya’s Saving Grace: A
Subject Matter Expert
Ananya eventually reached out to
a Subject Matter Expert specialising in Insuranceclaim-related issues and claimrejection-related issues. They combed through her documents.
Her procedure — a laparoscopic
surgery — was a package treatment at
that hospital. By definition, the package already includes consumables such as
drapes, syringes, surgical gloves, IV sets, and dressing material.Every item
deducted under “non-payable” belonged inside the package. Every rupee deducted
was incorrect.
Right?
However, this 'package'
definition is for hospital billing purposes only. The hospital ‘bundles’ items
for administrative simplicity, offering a single price for the entire
procedure. This ensures all the hospital's costs are covered in one
transaction.
A standard health insurance plan
(without a specialized consumables add-on
cover.) in India often categorises these same items as non-payable
consumables.
After demanding an itemized bill
from the hospital and comparing it rigorously against her policy's list of
non-payable items, she found a few critical discrepancies.a duplicate entry for
an IV, a few mislabeled items which were re-evaluated and covered.
In the end she could recover
around ₹12,000. The rest she had to pay out-of-pocket.
4. Where Policyholders Actually Have Power
Ananya's experience highlights a
vital truth about health insurance short settlements: insurers rely heavily on
standardized exclusion lists, and hospital billing errors are common.
By challenging the deduction with
evidence, you can ensure you're only paying for legitimate, non-covered
expenses, not the hospital's mistakes.
The core lesson for navigating a
short-settled claim remains clear:
● Know
your policy: Understand your coverage and exclusions before hospitalization.
● Get
an itemized bill: Always request and review a detailed itemized hospital bill
to check for discrepancies.
● Don't
be afraid to contest discrepancies: If you find errors or questionable
"non-payable items," formally contest the health insurance claim for
re-evaluation."
Most policyholders never contest
these points because they don’t know they exist. Experts do — and this difference is often
what recovers money people never knew they lost.
Hospitals handle volume.
Insurers handle compliance. TPAs handle timelines.
No one has the bandwidth to
manually cross-check every consumable against every policy wording for every
patient.
You know who does have that bandwidth?
Subject Matter Experts who work
exclusively on claim settlement,
short settlements, claim rejections and
Insurance claim-related issues.
They decode the system, identify what’s fair, and ensure the
policyholder gets exactly what they are contractually entitled to — not a rupee
less.
Conclusion
Before You Accept a Short
Settlement… Pause.
If you see unexplained deductions
or a sudden chunk missing under “non-payable items,” remember this:
A short settlement is not a final claim settlement. It’s just the
settlement you got before anyone contested it.
A Subject Matter Expert can catch
what the system misses, question what isn’t justified, and recover what you
didn’t know you could claim.
The
difference is not aggression.
The difference is expertise.
.jpg)
0 Comments