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Home › Referrals Claim help › Grounds

Claim exceeds the sum insured or a sub-limit

This means the claim was payable in principle but the amount exceeded the cover available.

HELP · DRAPTO
● Answer on this page
● Jargon translated
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✓ written for 11pm, not the demo
What happens nowThe version everybody runs, on paper
Where it failsThe step nobody owns
What to changeOne thing, this week
Drapto is not an insurance advisor, broker or agent, and is not registered with IRDAI in any such capacity. This page provides general information about the claims and grievance process and about published Insurance Ombudsman decisions. It is not advice on your specific claim. For advice on your policy, contact your insurer or a licensed advisor.
In short

This means the claim was payable in principle but the amount exceeded the cover available.

What this ground actually means.

Worth checking against restore benefits, top-up policies and whether earlier claims in the year consumed the sum insured.

How this ground is actually applied

The claim is larger than the cover available for the year. The available figure is not always the headline one: earlier claims in the same year reduce it, and a no-claim bonus or restore benefit may increase it.

What it turns on

What the correct available balance was on the date of admission, after earlier claims and any bonus or restoration.

Three things people get wrong about it

“The sum insured is the number on the certificate.”

It is the balance after claims already paid this year, plus any accrued bonus.

“A restore benefit applies automatically.”

It usually has conditions, often that the exhaustion relates to a different illness. Check whether yours applies.

“Only one policy can pay.”

If you hold more than one policy, or have employer cover as well, the balance may be claimable elsewhere.

What to check in your own documents

  • The sum insured plus any accrued no-claim bonus, as at the admission date.
  • Every claim already paid in the same policy year.
  • Whether a restore or refill benefit exists and whether its conditions are met.
  • Any second policy or employer group cover.
  • Whether the deduction is genuinely exhaustion, or a sub-limit being described loosely.

Two sections are missing from this page. The standard policy wording for this ground, and what the Insurance Ombudsman has actually held in published awards. Both are being compiled from the Council for Insurance Ombudsmen’s own reports. Neither will appear here until it can be cited, because a page that invented an award reference would be worse than a page that admits the gap.

The escalation process and deadlines

  1. The insurer's grievance officer. Response due within 15 days.
  2. IRDAI Bima Bharosa — bimabharosa.irdai.gov.in — if the insurer does not resolve it.
  3. The Insurance Ombudsman. Free, no lawyer required, and the award binds the insurer up to the prescribed limit.
  4. Consumer forum, if you choose to go further.

Ask about your rejection letter

Sahayak · claim informationRuns in your browser

Nothing you type is sent anywhere. Sahayak explains grounds and process — it cannot assess your specific claim or predict an outcome.

Related grounds

Pre-existing disease and non-disclosureWaiting period not completedRoom rent cap and proportionate deductionSub-limit on a specific procedure or conditionTreatment excluded under the policyNot medically necessaryDay-care procedure not coveredDocumentation incomplete or illegibleDelayed intimation to the insurerCashless denied, reimbursement route requiredPolicy lapsed or premium unpaidTreatment outside the networkPre and post hospitalisation outside the windowConsumables and non-medical items

Sources

  • Council for Insurance Ombudsmen — published awards and annual reports, cioins.co.in
  • IRDAI annual report and Bima Bharosa, irdai.gov.in
  • Insurance Ombudsman Rules 2017

You do not have to work this out alone.

Sahayak explains the grounds your insurer gave and the official escalation path. It is an information service, not an insurance advisor.

Check your rejectionThe ombudsman route