IRDAI 2024 Clause 19 Statutory Compliance
CIO Jurisdiction: All 17 Centres
Award Ref: CIO/TPA-CODE/R&C/2024
TPA Rejection Code R&C — Reasonable & Customary Arbitrary Deduction
Statutory Defense under Insurance Ombudsman Precedents & IRDAI Guidelines • Legal Ground: Arbitrary Tariff Capping
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 |
|---|---|---|---|---|---|
| Disputed line items under Code R&C | ₹80,000 | ₹32,000 | ₹80,000 | ₹32,000 | Insurance Ombudsman Precedents & IRDAI Guidelines |
Verbatim IRDAI Circulars & Statutory Citations
Statutory Defense — Insurance Ombudsman Precedents & IRDAI Guidelines
Reasonable & Customary deductions must be backed by published territorial fee schedules and cannot be levied arbitrarily on standard hospital bills.
Citation: IRDAI Master Circular dated May 29, 2024
Frequently Asked Questions (Pan-India & Vernacular Legal Guidance)
Is TPA deduction code R&C legally challengeable?
Yes. Reasonable & Customary deductions must be backed by published territorial fee schedules and cannot be levied arbitrarily on standard hospital bills. You can serve the ReclaimBill 2-Page statutory notice to overturn this deduction immediately.