IRDAI 2024 Clause 19 Statutory Compliance
CIO Jurisdiction: All 17 Centres
Award Ref: CIO/INSURER/FHPL-TPA/2024
Family Health Plan Insurance TPA (FHPL) Cashless Claim Deductions — IRDAI 2024 Statutory Audit
IRDAI Reg: TPA-007 • Average Deduction Variance: 16.8% • Average Discharge TAT: 4.5 hrs
Total Hospital Billed
₹250,000
Arbitrary TPA Cut
₹48,500
Legally Recoverable
₹48,500
Deterministic Math Comparison: TPA Cut vs. IRDAI May 2024 Statutory Math
| Line Item / Disputed Component | Billed (₹) | TPA Cut (₹) | Statutory Approved (₹) | Recoverable Overcharge (₹) | IRDAI Statutory Reference |
|---|---|---|---|---|---|
| Proportionate scaling on Titanium Knee Joint / Stent | ₹100,000 | ₹25,000 | ₹100,000 | ₹25,000 | Clause 19: Fixed MRP implants protected |
| Disallowed OT sterile supplies & consumable packs | ₹20,000 | ₹12,000 | ₹20,000 | ₹12,000 | Annexure-1: Essential operative supplies |
| Discharge approval delay holding fee (>3.0 hrs) | ₹4,000 | ₹4,000 | ₹0 | ₹4,000 | Clause 6.1: Holding fees cannot be billed |
Verbatim IRDAI Circulars & Statutory Citations
IRDAI Master Circular 2024 — Clause 19 & 6.1
Family Health Plan Insurance TPA (FHPL) is statutorily bound by IRDAI Master Circular Ref: IRDAI/HLT/CIR/PRO/84/5/2024.
Citation: IRDAI Regulatory Enforcement
Frequently Asked Questions (Pan-India & Vernacular Legal Guidance)
Can Family Health Plan Insurance TPA (FHPL) deduct money from implants or pharmacy if I chose a higher room category?
No. Under IRDAI Master Circular 2024 Clause 19, Family Health Plan Insurance TPA (FHPL) can ONLY proportionately reduce associated room charges like doctor consultation. Implants, stents, medicines, and ICU fees are strictly protected.