T09 · 26 documents tagged to this reason
“Reasonable & customary charges” — and other short-settlements
This is the single most winnable node in our corpus. The claim was already admitted — the insurer just paid less than the bill. The consistent pattern across real awards: the ombudsman demands the insurer prove its deduction with a written clause or a comparative rate chart, and it usually can't.
How insurers word it
- Deducted as per reasonable and customary charges
- Lens/implant cost restricted to internal cap
- Pre- and post-hospitalisation folded into the surgery sub-limit
- Visit charges disallowed as per internal fee gradation
Arguments that have beaten this
C-T09-1
"Reasonable and customary" needs comparative evidence
A "reasonable and customary" deduction is arbitrary unless the insurer produces comparative rate evidence for the same treatment, in the same area, at the time. Without that, the cut is exactly what several awards have called it: an abuse of process.
Source
OA-006, OA-010, OA-014, OA-015, OA-016 — five separate reversals on identical reasoning. OA-029 — an internal fee "gradation" clawback rejected because charges legitimately vary by hospital, and the insured is free to choose.
Where this argument fails
The policy contains an explicit numeric sub-limit for that item — then the fight is only about the amount above the written limit, not the limit itself.
C-T09-2
Every deducted line must trace to something written
A deduction must trace to a specific clause in your policy or the IRDAI non-payable-items list. Ceilings that appear nowhere in your policy terms cannot be invented after the fact, and benefits like pre- and post-hospitalisation cannot be folded into an unrelated sub-limit.
Source
OA-008 (visit-charge ceiling absent from the terms — deduction reversed); OA-012 (no lens-cost limit in the policy — full IOL cost allowed); OA-017 (pre/post-hospitalisation payable in addition to the surgery sub-limit). Contrast OA-011, where the IRDAI non-payable list was correctly applied and the deduction upheld.
Where this argument fails
The deduction implements an explicit written clause — a co-pay percentage, or an item genuinely on the standard non-payable list.
We publish the losing side too. An appeal built on an argument that does not fit your facts wastes the one year you have.
The insurer paid my claim but cut 30% as "reasonable and customary charges", with no explanation. Can I contest just that?
Yes, and this is the strongest node in our whole corpus for exactly that fight. Ask the insurer, in writing, for the comparative rate chart it used. Five separate awards in our corpus reversed this kind of deduction because the insurer could not produce one.
My pre- and post-hospitalisation expenses were counted against my surgery sub-limit. Is that right?
Not necessarily. In one corpus award, pre- and post-hospitalisation expenses were held payable in addition to the surgery sub-limit — they are a separate benefit, not a sub-item of it, unless your specific policy wording says otherwise.
Is this the reason on your letter?
Ladai will read your specific letter and policy and tell you which of these arguments actually reaches your facts — and how strong that makes your case.
Get your verdict on this