List of Expenses Generally Excluded (‘Non-admissible Expenses’) in Hospitalisation Policy
GUIDELINES ON STANDARDISATION IN HEALTH INSURANCE – IRDA CIRCULAR No IRDA/HLT/CIR/036/02/2013 DATED 20.02.2013
Items
Suggestions
1
Hair Removing Cream
Not Payable
2
Baby Charges (unless specified/indicated)
Not Payable
3
Baby Food
Not Payable
4
Baby Utilites Charges
Not Payable
5
Baby Set
Not Payable
6
Baby Bottles
Not Payable
7
Brush
Not Payable
8
Cosy Towel
Not Payable
9
Hand Wash
Not Payable
10
Moisturiser Paste Brush
Not Payable
11
Powder
Not Payable
12
Razor
Payable
13
Shoe Cover
Not Payable
14
Beauty Services
Not Payable
15
Belts/ Braces
Essential and Should be Paid at least Specifically for Cases who have undergone surgery of
Thoracic or Lumbar Spine.
16
Buds
Not Payable
17
Barber Charges
Not Payable
18
Caps
Not Payable
19
Cold Pack/Hot Pack
Not Payable
20
Carry Bags
Not Payable
21
Cradle Charges
Not Payable
22
Comb
Not Payable
23
Disposable Razor Charges ( For Site Preparations)
Payable
24
Eau-De-Cologne / Room Freshners
Not Payable
25
Eye Pad
Not Payable
26
Eye Sheild
Not Payable
27
Email / Internet Charges
Not Payable
28
Food Charges (other than Patient’s Diet Provided by Hospital)
Not Payable
29
Foot Cover
Not Payable
30
Gown
Not Payable
31
Leggings
Essential in Bariatric and Varicose Vein Surgery and may be considered for at least these
conditions where Surgery itself is Payable.
32
Laundry Charges
Not Payable
ANNEXURE IV
List of Expenses Generally Excluded (‘
Non-admissible Expenses
‘) in Hospitalisation Policy
GUIDELINES ON STANDARDISATION IN HEALTH INSURANCE – IRDA CIRCULAR No IRDA/HLT/CIR/036/02/2013 DATED 20.02.2013
Toiletries/ Cosmetics/ Personal Comfort or Convenience Items
33
Mineral Water
Not Payable
34
Oil Charges
Not Payable
35
Sanitary Pad
Not Payable
36
Slippers
Not Payable
37
Telephone Charges
Not Payable
38
Tissue Paper
Not Payable
39
Tooth Paste
Not Payable
40
Tooth Brush
Not Payable
41
Guest Services
Not Payable
42
Bed Pan
Not Payable
43
Bed Under Pad Charges
Not Payable
44
Camera Cover
Not Payable
45
Cliniplast
Not Payable
46
Crepe Bandage
Not Payable/ Payable by the Patient
47
Curapore
Not Payable
48
Diaper Of Any Type
Not Payable
49
DVD, CD Charges
Not Payable ( However if CD is specifically sought by Insurer/TPA then Payable)
50
Eyelet Collar
Not Payable
51
Face Mask
Not Payable
52
Flexi Mask
Not Payable
53
Gause Soft
Not Payable
54
Gauze
Not Payable
55
Hand Holder
Not Payable
56
Hansaplast/ Adhesive Bandages
Not Payable
57
Infant Food
Not Payable
58
Slings
Reasonable costs for one sling in case of Upper Arm Fractures may be considered
B
59
Weight Control Programs/ Supplies/ Services
Exclusion in Policy unless otherwise specified
60
Cost Of Spectacles/ Contact Lenses/ Hearing Aids Etc.,
Exclusion in Policy unless otherwise specified
61
Dental Treatment Expenses that do not require Hospitalisation
Exclusion in Policy unless otherwise specified
62
Hormone Replacement Therapy
Exclusion in Policy unless otherwise specified
63
Home Visit Charges
Exclusion in Policy unless otherwise specified
64
Infertility/ Subfertility/ Assisted Conception Procedure
Exclusion in Policy unless otherwise specified
65
Obesity (including Morbid Obesity) Treatment if Excluded in Policy
Exclusion in Policy unless otherwise specified
66
Psychiatric & Psychosomatic Disorders
Exclusion in Policy unless otherwise specified
67
Corrective Surgery for Refractive Error
Exclusion in Policy unless otherwise specified
68
Treatment of Sexually Transmitted Diseases
Exclusion in Policy unless otherwise specified
69
Donor Screening Charges
Exclusion in Policy unless otherwise specified
70
Admission/Registration Charges
Exclusion in Policy unless otherwise specified
Items Specifically Excluded in Policies
71
Hospitalisation for Evaluation/ Diagnostic Purpose
Exclusion in Policy unless otherwise specified
72
Expenses for Investigation/ Treatment irrelevant to the Disease for which
admitted or diagnosed
Exclusion in Policy not payable unless otherwise specified
73
Any Expenses when the Patient is diagnosed with Retro Virus + or suffering
from /HIV/ Aids etc is detected/ directly or indirectly
Not Payable as per HIV/ AIDS Exclusion
74
Stem Cell Implantation/ Surgery & Storage
Not Payable except Bone Marrow Transplantation where covered by Policy
C
75
Ward and Theatre Booking Charges
Payable Under OT Charges, Not Payable Separately
76
Arthroscopy & Endoscopy Instruments
Rental Charged By The Hospital Payable. Purchase of Instruments Not Payable.
77
Microscope Cover
Payable Under OT Charges, Not Payable Separately
78
Surgical Blades,Harmonic Scalpel, Shaver
Payable Under OT Charges, Not Payable Separately
79
Surgical Drill
Payable Under OT Charges, Not Payable Separately
80
Eye Kit
Payable Under OT Charges, Not Payable Separately
81
Eye Drape
Payable Under OT Charges, Not Payable Separately
82
X-Ray Film
Payable Under Radiology Charges, Not as Consumable
83
Sputum Cup
Payable Under Investigation Charges, Not as Consumable
84
Boyles Apparatus Charges
Part Of Ot Charges, Not Seperately
85
Blood Grouping and Cross Matching of Donors Samples
Part Of Cost Of Blood, Not Payable
86
Antiseptic & Disinfectant Lotions
Not Payable-Part of Dressing Charges
87
Band Aids, Bandages, Sterile Injections, Needles, Syringes
Not Payable – Part of Dressing Charges
88
Cotton
Not Payable-Part of Dressing Charges
89
Cotton Bandage
Not Payable-Part of Dressing Charges
90
Micropore/ Surgical Tape
Not Payable-payable by the Patient when Prescribed, otherwise included as Dressing
Charges
91
Blade
Not Payable
92
Apron
Not Payable -Part of Hospital Services/Disposable Linen to be Part of OT/ ICU Charges
93
Torniquet
Not Payable (service is charged by Hospitals, Consumables cannot be separately charged)
94
Orthobundle, Gynaec Bundle
Part of Dressing Charges
95
Urine Container
Not Payable
D
96
Luxury Tax
Policy Exclusion – Not Payable.
If there is no Policy Exclusion, then Actual Tax Levied by
Government is Payable – Part of Room Charge for Sub Limits
97
HVAC
Part of Room Charge Not Payable Separately
98
House Keeping Charges
Part of Room Charge Not Payable Separately
99
Service Charges where Nursing Charge also charged
Part of Room Charge Not Payable Separately
100
Television & Air Conditioner Charges
Payable Under Room Charges Not if separately levied
101
Surcharges
Part of Room Charge Not Payable Separately
Elements of Room Charge
Items Which form Part of Hospital Services where Separate Consumables are not Payable but the Service is
102
Attendant Charges
Not Payable – Part of Room Charges
103
IM/ IV Injection Charges
Part of Nursing Charges, Not Payable
104
Clean Sheet
Part of Laundry/housekeeping Not Payable Separately
105
Extra Diet of Patient(other than that which forms part of Bed Charge)
Not Payable
. Patient Diet Provided by Hospital is Payable
106
Blanket/Warmer Blanket
Not Payable- Part of Room Charges
E
107
Admission Kit
Not Payable
108
Birth Certificate
Not Payable
109
Blood Reservation Charges and Ante Natal Booking Charges
Not Payable
110
Certificate Charges
Not Payable
111
Courier Charges
Not Payable
112
Convenyance Charges
Not Payable
113
Diabetic Chart Charges
Not Payable
114
Documentation Charges / Administrative Expenses
Not Payable
115
Discharge Procedure Charges
Not Payable
116
Daily Chart Charges
Not Payable
117
Entrance Pass / Visitors Pass Charges
Not Payable
118
Expenses Related to Prescription on Discharge
To be Claimed by Patient under Post -Hospitalisation where admissible
119
File Opening Charges
Not Payable
120
Incidental Expenses / Misc. Charges (not Explained)
Not Payable
121
Medical Certificate
Not Payable
122
Maintainance Charges
Not Payable
123
Medical Records
Not Payable
124
Preparation Charges
Not Payable
125
Photocopies Charges
Not Payable
126
Patient Identification Band / Name Tag
Not Payable
127
Washing Charges
Not Payable
128
Medicine Box
Not Payable
129
Mortuary Charges
Payable Upto 24 Hrs, Shifting Charges Not Payable
130
Medico Legal Case Charges (MLC Charges)
Not Payable
F
131
Walking Aids Charges
Not Payable
132
Bipap Machine
Not Payable
133
Commode
Not Payable
134
CPAP/ CPAD Equipments Device
Not Payable
135
Infusion Pump – Cost
Not Payable
136
Oxygen Cylinder (for Usage outside the Hospital)
Not Payable
137
Pulseoxymeter Charges Device
Not Payable
138
Spacer
Not Payable
Administrative or Non-medical Charges
External Durable Devices
139
Spirometre
Not Payable
140
SPO2 Probe
Not Payable
141
Nebulizer Kit
Not Payable
142
Steam Inhaler
Not Payable
143
Armsling
Not Payable
144
Thermometer
Not Payable (paid By Patient)
145
Cervical Collar
Not Payable
146
Splint
Not Payable
147
Diabetic Foot Wear
Not Payable
148
Knee Braces ( Long/ Short/ Hinged)
Not Payable
149
Knee Immobilizer/Shoulder Immobilizer
Not Payable
150
Lumbo Sacral Belt
Essential and should be paid at least specifically for cases who have undergone Surgery of
Lumbar Spine
151
Nimbus Bed or Water or Air Bed Charges
Payable for any ICU Patient requiring more than 3 Days in ICU; All Patients with Paraplegia/
Quadriplegia for any reason and at Reasonable Cost of approximately Rs 200/Day
152
Ambulance Collar
Not Payable
153
Ambulance Equipment
Not Payable
154
Microsheild
Not Payable
155
Abdominal Binder
Essential and should be Paid at least in Post Surgery Patients of Major Abdominal Surgery
Including TAH, LSCS, Incisional Hernia Repair, Exploratory Laparotomy for Intestinal
Obstruction, Liver Transplant Etc.
G
156
Betadine \ Hydrogen Peroxide\spirit\ Disinfectants Etc
May be Payable when prescribed for Patient, Not Payable for Hospital use in OT or Ward or
for dressings ward or for dressings
157
Private Nurses Charges- Special Nursing Charges
Post Hospitalization Nursing Charges Not Payable
158
Nutrition Planning Charges – Dietician Charges- Diet Charges
Patient Diet provided by Hospital is Payable
159
Sugar Free Tablets
Payable -Sugar Free variants of admissable medicines are not Excluded
160
Cream Powder Lotion (Toileteries are Not Payable, only Prescribed Medical
Pharmaceuticals Payable)
Payable when Prescribed
161
Digene Gel
Payable when Prescribed
162
ECG Electrodes
Upto 5 Electrodes are Required for every case visiting OT or ICU. For longer stay in ICU,
may Require a Change and at least one set every second day must be Payable.
163
Gloves
Sterilized Gloves Payable / Unsterilized Gloves not payable
164
HIV Kit
Payable – Pre-Operative Screening
165
Listerine/ Antiseptic Mouthwash
Payable When Prescribed
166
Lozenges
Payable When Prescribed
167
Mouth Paint
Payable When Prescribed
Items Payable If Supported By A Prescription
168
Nebulisation Kit
If used during Hospitalization is Payable Reasonably
169
Novarapid
Payable When Prescribed
170
Volini Gel/ Analgesic Gel
Payable When Prescribed
171
Zytee Gel
Payable When Prescribed
172
Vaccination Charges
Routine Vaccination Not Payable / Post Bite Vaccination Payable
H
173
AHD
Not Payable – Part of Hospital’s Internal Cost
174
Alcohol Swabes
Not Payable – Part of Hospital’s Internal Cost
175
Scrub Solution/ Sterillium
Not Payable – Part of Hospital’s Internal Cost
I
176
Vaccine Charges for Baby
Not Payable
177
Aesthetic Treatment / Surgery
Not Payable
178
TPA Charges
Not Payable
179
Visco Belt Charges
Not Payable
180
Any Kit with no details mentioned [Delivery Kit, Orthokit, Recovery Kit, Etc]
Not Payable
181
Examination Gloves
Not Payable
182
Kidney Tray
Not Payable
183
Mask
Not Payable
184
Ounce Glass
Not Payable
185
Outstation Consultant’s/ Surgeon’s Fees
Not Payable, Except For Telemedicine Consultations
Where Covered by Policy
186
Oxygen Mask
Not Payable
187
Paper Gloves
Not Payable
188
Pelvic Traction Belt
Should be Payable in case of PIVD requiring traction as this is generally not reused
189
Referal Doctor’s Fees
Not Payable
190
Accu Check ( Glucometery/ Strips)
Not Payable. Pre-Hospitilasation or Post-Hospitalisation / Reports and Charts Required/
Device Not Payable
191
Pan Can
Not Payable
192
Sofnet
Not Payable
193
Trolly Cover
Not Payable
194
Urometer, Urine Jug
Not Payable
195
Ambulance
Payable – Ambulance from home to Hospital or inter-hospital shifts is Payable/ RTA – As
Specific Requirement for critical injury is Payable)
196
Tegaderm / Vasofix Safety
Payable – Maximum of 3 in 48 Hrs and then 1 in 24 Hrs
197
Urine Bag
Payable where medicaly necessary till a reasonable cost – Maximum 1 Per 24 Hrs
198
Softovac
Not Payable
199
Stockings
Essential for case like CABG etc. Where it should be paid.
OTHERS
Part of Hospital’s own Costs and not Payable