A short payment (partial claim approval) happens when the insurer does not cover the full hospitalization bill, stating that the hospital stay was "not justified." This means they believe:

✔ You could have been treated as an outpatient (OPD) instead of hospitalization.
✔ The stay was longer than medically necessary.
✔ The treatment could have been done without admission.

1. Why Do Insurers Deny Full Payment for Hospital Stay?

1. Treatment Was Not Medically Necessary for Hospitalization

Example: A minor fever that could have been treated with OPD care but resulted in a two-day hospital stay.

Solution:

✔ Ensure your doctor clearly documents the necessity of hospitalization in the discharge summary.

2. Exceeding Medically Justified Stay Duration

Example: If your insurer believes you stayed longer than needed post-surgery and denies extra days.

Solution:

✔ Keep medical justification and reports from the doctor explaining the extended stay.

✔ Request a detailed discharge summary explaining why continued hospitalization was required.

3. Admission for Diagnostic Tests Only

Example: If you were hospitalized just for lab tests and scans without actual treatment.

Solution:

✔ Ensure your doctor documents treatment procedures along with tests in your medical records.

✔ Some insurers allow daycare hospitalization—check your policy coverage.

2. What to Do If Your Insurance Pays Less Due to "Stay Not Justified"?

Step 1: Get Written Reason for Short Payment

• Ask your insurer for a formal explanation of why they reduced your claim.

Step 2: Check Your Medical Records

• Ensure all medical reports, prescriptions, and discharge summaries justify the hospital stay.

Step 3: Request a Medical Necessity Letter from Your Doctor

• A detailed letter from your doctor explaining why hospitalization was needed can help.

Step 4: File a Claim Appeal

• If you believe the decision was unfair, submit an appeal with additional documents supporting your case.

Step 5: Escalate to the Insurance Ombudsman

• If your appeal is denied and you still believe your claim is valid, contact the IRDAI Insurance Ombudsman.

3. How to Avoid "Stay Not Justified" Rejections in the Future?

✔ Confirm hospitalization necessity with your doctor beforehand.

✔ Keep all medical reports, test results & prescriptions.

✔ Understand what your policy covers for hospitalization.

✔ Check if your treatment qualifies under "Daycare Procedures" to avoid unnecessary hospital stay.

✔ Ask the hospital to document every medical reason for admission.

Key Takeaway: If your insurer reduces payment due to "Stay Not Justified," get a detailed explanation, collect strong medical proof, appeal the decision, and escalate if needed.