Payer
SBI General claims, and where the money actually goes.
This page describes mechanisms, not conduct. We publish no rejection rate for SBI General Insurance and no comparison against any other insurer — we have not measured one, and a number we cannot show the working for is not worth reading.
Most money lost on a SBI General claim is deducted, not refused. The claim is approved and paid at less than billed, each reduction traceable to a clause — most often a room-rent limit re-pricing associated charges, a pre-authorisation that no longer describes what happened, or a query answered after the window closed. This page describes those mechanisms. It publishes no settlement rate for SBI General and no comparison with any other insurer.
A deduction is not a rejection.
The commonest surprise on a SBI General settlement is a claim that was approved and still paid less than billed. Nothing was refused — everything was scaled.
The three that account for most of it
Room rent cap
If the room exceeds the policy limit, associated charges reduce in the same proportion. A ₹8,000 breach does not cost ₹8,000 — it reduces the surgeon, the anaesthetist and the theatre by the same ratio.
Fixable: at admission, before the patient is in the room.
Pre-authorisation scope
An approval covers what was described. A procedure that changed in theatre, or a longer stay, needs an enhancement raised while the patient is still admitted rather than explained afterwards.
Fixable: during the stay.
The query window
A query has a deadline set in the policy and the empanelment contract. A claim closed because nobody replied was not rejected on merit — it expired.
Fixable: with a countdown, not a person remembering.
What we will not tell you about SBI General
What other sites publish
- A rejection percentage with no method behind it
- A ranking of insurers by “claim friendliness”
- Which payer to avoid
- What you would recover by switching
What is on this page
- How a proportionate deduction is calculated
- Which deductions are decided before discharge
- The Ombudsman route if the grievance process is exhausted
- Arithmetic you can redo with your own claims
If the grievance process is exhausted
Every insurer has an internal grievance route, and it has to be used first. After that, the Insurance Ombudsman for your jurisdiction takes complaints about repudiation, partial settlement and delay. Which office covers you depends on where the policy was issued — the jurisdictions are listed here.
Where the money actually goes.
Mechanism, not measurement. Neither figure below is a claim about this payer.
- Billed
- Deducted
- Settled
Every step is a named reduction with a clause behind it. None of them is a refusal, and none of them is a surprise once you know which clause applies. This shape is generic to Indian health insurance; it is not a measurement of SBI General.
Illustrative arithmetic. Your own figures will differ.- 58 settled in full
- 27 settled short
- 11 open past 60 days
- 4 written off
The twenty-seven in the middle are the argument. Not refused — paid less than billed, each for a stated reason.
Illustrative arithmetic. Your own figures will differ.A multi-line general insurer settles differently
SBI General writes health alongside motor, fire and marine, and health claims sit inside that larger operation.
A TPA usually holds the file
Multi-line general insurers commonly appoint a third-party administrator for health. The TPA issues the pre-authorisation, runs the query and prepares the settlement — so the query window and the escalation both start with them, not the insurer.
Two contracts, not one
The tariff sits in the hospital's agreement with the TPA or network; the cover sits in the patient's policy with the insurer. A deduction can come from either, and they are argued in different places.
Group policies behave differently from retail
An employer group policy may waive waiting periods, alter room limits or add a co-pay that the retail product does not carry. Establish which one the patient holds before quoting a limit.
Escalation runs through the TPA first
Going to the insurer's grievance officer with a query the TPA never closed usually returns it to the TPA and costs a cycle.
What actually decides the number
Four documents. The clinical file is not one of them.
The policy schedule
Room-rent limit, co-pay, sub-limits by procedure, waiting periods and any restriction carried from an earlier policy. This document decides more of the settlement than the clinical file does, and the hospital usually has not read it.
The tariff you agreed
The rate card in the network agreement, and which version of it. A bill raised above the agreed rate reduces to the agreed rate, whatever the reason for the higher figure.
The pre-authorisation letter
It describes a planned procedure and a sanctioned amount. If theatre went differently, an enhancement raised during the stay is a different conversation from a representation raised after discharge.
The settlement advice
The only document that says why. Read it against the four above and each reduction resolves into predictable, contractual, or unexplained — and only the third is worth a representation.
The clock, and where it runs out
Four moments. Three of them are before the money is at stake.
At admission
Room class checked against the policy limit before the patient is in the bed. This is the single cheapest intervention on the list and the one most often missed.
At 85% of sanction
Enhancement raised while the patient is admitted. After discharge the same request is a representation, and it is judged differently.
On a query
Insurers and TPAs set a response window and state it on the query itself. An unanswered query does not stay open — it closes at whatever the insurer decided.
On the settlement advice
The clock on contesting a deduction starts when the advice is issued, not when somebody opens it.
If the insurer's own process is exhausted
Three steps, in order. Skipping one is the usual reason the next stage sends it back.
The insurer's grievance officer
Every insurer publishes one. Write to them, keep the reference, and give them the stated turnaround before going further.
IRDAI's Bima Bharosa portal
The regulator's grievance channel. It records the complaint against the insurer and puts a clock on it.
The Insurance Ombudsman
Established under the Insurance Ombudsman Rules 2017, free to the complainant, and binding on the insurer if the award is accepted. There are eligibility conditions and a monetary ceiling — check the current rules before filing. The route, in detail.
Questions we are actually asked
Does Drapto publish a rejection rate for SBI General?
No. We have not measured one, and a figure we cannot show the working for is not worth reading. We publish no settlement rate for any payer and no comparison between payers.
Why was the claim approved and still paid less?
Because approval and pricing are separate decisions. A claim can clear on clinical grounds and still reduce on a room-rent proportion, a tariff version, a sub-limit or an unattached document.
A room upgrade cost ₹8,000. Why did the settlement drop by much more?
Under proportionate deduction, exceeding a room-rent limit re-prices the associated heads on the same bill in the same ratio — surgeon, anaesthetist, theatre, investigations. The room is the trigger, not the size of the loss.
Can this be fixed after discharge?
Some of it. Most of it is cheaper to prevent: the room class at admission, the enhancement during the stay, the query inside its window. After discharge the same facts are argued instead of recorded.
The same mechanics, other payers.
- Aditya Birla HealthHow deductions happen
- Bajaj AllianzHow deductions happen
- Care HealthHow deductions happen
- CGHSHow deductions happen
- ECHSHow deductions happen
- ESICHow deductions happen
Patients: Sahayak explains a rejection letter in plain language. Hospitals: Decoder separates predictable deductions from contractual ones on a settlement advice.
See these deductions on your own settlements.
Twenty settled claims, advices only, patient details redacted. We read them with you and name the clause behind each reduction.