Final bill audit

Audit a hospital bill line by line: room-rent cap, proportionate deduction, Annexure I items, co-pay and sum-insured cap, with the three-hour discharge timer.

The question it answers

How much of this hospital bill does the policy actually pay?

You give it: A policy (sum insured, room-rent cap, co-pay) and a bill, line by line.

You get: The deduction on every line with its rule and source, the amount payable, and a check of the three-hour discharge limit.

The idea

A hospital bill is cut down one line at a time, and every cut names the rule behind it.

Rules that run, in order

1. Room rent above the policy cap
2. Associated expenses reduced in the same proportion
3. Annexure I items not payable
4. Co-pay, then the sum-insured cap
5. The three-hour discharge limit

How well the rules are sourced

The three-hour limit is read in the Master Circular of 29 May 2024 (Official text). The proportionate-deduction and room-rent rules rest on the circular of 11 June 2020 as summarised elsewhere (Secondary), which the author confirms is operative. The ICU and consumables exemptions are Practice.

What it does not do

It does not know any insurer’s own policy wording, and it never decides a claim.

Steps

1. Describe the policy. Enter the sum insured, the room-rent cap (a share of the sum insured, a fixed amount, or none) and the co-pay. Say whether the hospital charges differently by room category.
2. Enter the bill. Add each line with its billing head. The room line carries the rate per day and the number of days. Mark any Annexure I item.
3. The room is tested against the cap. If the room costs more per day than the policy allows, the excess is deducted from the room line itself.
4. Associated expenses are reduced in proportion. When the hospital bills differently by room and the room was costlier than eligible, professional fees, operation theatre and procedure charges are cut by the same ratio. Pharmacy, implants, diagnostics, ICU and consumables are exempt.
5. Co-pay, then the sum-insured cap. The co-pay is taken from what is left, then the result is limited to the sum insured still available. Each deduction shows its rule and how well that rule is sourced.
6. Check the discharge timer and take the PDF. Enter when discharge was requested and when final authorisation came: beyond three hours the circular puts the extra charges on the insurer. Download the settlement sheet.

Every case on this site is synthetic. These are working drafts and illustrations, not a claim decision or legal advice. The interactive worksheets need JavaScript; nothing is sent anywhere.