Health insurance claim calculator

The calculator works through a bill in the order most policy wordings use. Your own policy wording decides the final amount.

1. 1
   Room and ICU limits. The policy pays room rent and ICU charges up to its daily limits. Anything above a limit is yours to pay.
2. 2
   Proportionate deduction. If your room costs more than the limit, many policies also pay doctors', theatre and procedure charges only in the same proportion.
3. 3
   Items the policy does not pay. These go straight to you and do not use up your sum insured.
4. 4
   Sub-limits. Some treatments, such as cataract surgery, have their own upper limit.
5. 5
   Deductible and co-payment. A deductible is a fixed amount you pay first. A co-payment is a percentage of the payable claim.
6. 6
   Sum insured still available. The policy cannot pay more than what is left of your sum insured and bonus this year.

A policy with a sum insured of ₹3,00,000 limits room rent to 2% of the sum insured, up to ₹5,000 a day, and has a 5% co-payment. The patient stays 4 days in a room that costs ₹8,000 a day, at a hospital that charges more for the same items in a higher room category.

The room is ₹3,000 a day above the limit, so the patient pays that ₹12,000 directly. Because the eligible rent (₹5,000) is 62.5% of the actual rent (₹8,000), the policy pays only 62.5% of the doctors', theatre and procedure charges, which costs the patient another ₹22,500.

At a hospital that charges the same rates in every room, or with a no-proportionate-deduction add-on, there is no proportionate deduction. The policy would then pay ₹1,14,000 and the patient ₹20,000. The room rent above the limit is still the patient's.

IRDAI's 2020 norm on proportionate deductions lets insurers reduce only the "associated medical expenses" that the policy defines, and only when the patient chooses a room above the eligible category.

IRDAI's 2024 master circular on health insurance replaced the 2020 circular, and no new text on proportionate deduction has replaced it. Current policy wordings still carry the same exemptions, so check the clause in your own policy.

These terms are defined in the Customer Information Sheet that comes with every health policy:

• Co-payment: a fixed percentage of the admissible claim that you pay. It does not reduce your sum insured.
• Deductible: an amount up to which the insurer pays nothing. It can apply per claim, per year or both.
• Sub-limit: a fixed upper limit for a particular treatment or expense. The insurer pays nothing above it.

No IRDAI rule fixes the order in which a deductible and a co-payment are applied, so the calculator lets you choose. Your policy wording decides.

IRDAI's 2019 standard list sorts items into four groups. Items on the first list, such as food for visitors, laundry, toiletries, attendant charges and walking aids, are not paid unless your policy covers them. Items on the other three lists, such as gloves, gowns, admission kits and registration charges, belong in room, procedure or treatment charges; the 2019 guidelines told insurers to make sure network hospitals don't bill them separately. IRDAI's 2024 master circular replaced those guidelines, but policy wordings still attach the list.

Look for the list in the annexure of your policy, and ask the hospital which items on your estimate it expects the insurer to refuse.

KASP / PMJAY, MEDISEP and CGHS pay fixed package rates at empanelled hospitals, so this calculator doesn't apply to them. MEDISEP also caps room rent according to the hospital's category. Choose the scheme at the top of the calculator for a short explanation, or read the cashless pre-approval guide.

• IRDAI, Master Circular on Health Insurance Business, 29 May 2024, and its annexures (the Customer Information Sheet format and the list of superseded circulars).
• IRDAI, Norms on Proportionate Deductions, 11 June 2020.
• IRDAI, Modification Guidelines on Standardization in Health Insurance, 27 September 2019, Annexure I (non-payable items).
• Standard Arogya Sanjeevani and group mediclaim policy wordings, for how room, ICU and proportionate-deduction clauses are written.

All checked on 12 October 2026.

What is proportionate deduction in health insurance?

If you choose a room that costs more than your policy's room rent limit, the insurer may pay doctors', theatre and procedure charges only in the same proportion as your eligible rent bears to the actual rent. For example, with a ₹5,000 limit and an ₹8,000 room, it pays 62.5% of those charges. Under IRDAI's 2020 norm, as most current policy wordings state, medicines, implants, tests and ICU charges are not cut this way.

Does the room rent limit also apply to ICU?

Most policies have a separate daily limit for ICU charges. ICU charges are not cut in proportion, but in some policy wordings an ICU above its limit can trigger a proportionate deduction on other charges. Choose that option in the calculator if your policy says so.

Is this what my insurer will pay?

No. It is an estimate based on the figures you enter. Your insurer decides what is payable under your policy wording, after seeing the hospital's bill.

Does the calculator work for KASP / PMJAY, MEDISEP or CGHS?

No. These schemes pay fixed package rates at empanelled hospitals, so this calculator doesn't model them. Choose the scheme in the calculator for a short explanation.

Are the figures I type saved or sent anywhere?

No. The calculation runs in your browser, and nothing you type is sent to Adserr or anyone else.