IRDAI says implants, ICU charges, pharmacy costs cannot be part of proportionate deductibles

Cost of medical devices, implants, pharmacy costs as well as ICU charges cannot be made part of proportionate deductibles under health insurance products in case a policyholder chooses a higher room category during treatment, said the insurance regulator.

A proportionate deductible is a concept wherein if anyone chooses a room category better than what the policy covers, they will have to pay the difference including the higher charges incurred on doctor fees or nurse expenses applicable to that room category.

Each health insurance product has a specific cap on the type of room that the insured can pick for treatment. Anything that is higher will have to be paid for, by the individual. For example, if an individual is eligible for room of Rs 1,000 per day, if he/she opts for a room that is chargeable at Rs 2,500, they will have to pay it out of their own pocket.

Earlier, pharmacy costs, implants/medical devices and cost of diagnostics was a part of associate medical expenses which made the policyholders pay for it in case a higher rent category room was chosen in a hospital. But from now on, this will no longer be the case. Insurance Regulatory and Development Authority of India (IRDAI) has said that insurers cannot apply proportionate deductions in hospitals which don’t follow differential billing based on the room category.

“Insurers are also not permitted to apply proportionate deduction for ‘ICU charges’ as different categories of ICU are not there,” said IRDAI. These guidelines will come in to force with immediate effect. Hence, all existing policies will also have to comply with it.