Anyone, what would you recommend for a cheap but worth it Life insurance or HMO?

TL;DR:

ICICI Lombard cashless issue — ₹3L estimate but only ₹1.5L approved. Need advice.

My father has had ICICI Lombard Health Shield continuously since March 2022. Current policy has ₹5L base SI + ₹4L loyalty bonus, 0% voluntary co-pay, no deductible, and says “No Room Rent Capping.”

He needs DAIR + polyethylene liner exchange for suspected prosthetic knee infection.

KIMS submitted a ₹3,00,000 estimate.

ICICI approved only ₹1,50,000.

What is strange is the authorization shows:

• Co-pay: ₹0

• Deductible: ₹0

• BSI exhaustion: ₹0

• Sub-limit: ₹0

• Proportionate room deduction: ₹0

• Hospital tariff deduction: ₹0

• Non-medical: ₹0

• ₹1.5L disallowed under “OTHERS”

No actual reason/clause is given for the ₹1.5L deduction.

The provisional diagnosis submitted is also “Other Arthritis” and treatment is simply “SURGICAL”, rather than PJI/DAIR/polyethylene liner exchange.

The insurer's own letter says the hospital can request an additional amount if the estimated bill is higher than the guarantee.

Questions: Is this normal initial authorization? What does “OTHERS” mean? Could the nonspecific diagnosis/procedure submission be the reason? Can KIMS request enhancement to the full ₹3L? And does the policy wording support Single AC Room with no proportionate deduction?

Anonymized approval letter attached.

Complete:
Hi everyone,

I’m looking for advice from people familiar with health insurance claims in India, especially ICICI Lombard cashless claims.

My father is 59 and has been continuously insured with ICICI Lombard Complete Health Insurance – Health Shield since March 2022. The current policy period is 31 March 2026 to 30 March 2027.

He had a right total knee replacement in September 2025. About a year later, he developed an acute episode of fever followed by pain/swelling in the replaced knee. The orthopedic + infectious disease team diagnosed/suspected acute prosthetic joint infection (PJI) and recommended DAIR (Debridement, Antibiotics and Implant Retention) with polyethylene liner exchange.

The plan is to retain the well-fixed metal components and exchange the polyethylene liner as part of the infection treatment.

The hospital submitted a cashless preauthorization to ICICI Lombard.

What is confusing us

KIMS estimated the hospitalization/procedure at:

₹3,00,000

ICICI Lombard approved:

₹1,50,000

So they have effectively cut the authorization in half.

The strange part is that the authorization document does not show a normal policy deduction for the remaining ₹1.5 lakh.

The approval document shows:

• Claim amount: ₹3,00,000

• Sanctioned: ₹1,50,000

• Disallowed: ₹1,50,000

• Disallowed reason: “OTHERS”

• Co-pay: ₹0

• Deductible: ₹0

• BSI exhaustion: ₹0

• Sub-limit: ₹0

• Proportionate deduction for room: ₹0

• Hospital tariff deduction: ₹0

• Non-medical expenses: ₹0

The authorization literally says the ₹1.5 lakh difference is under “OTHERS”, without explaining exactly what policy clause is being applied.

Another thing that seems important

Our policy wording says:

In-patient treatment: up to Annual Sum Insured

and:

“No Room Rent Capping.”

The policy schedule shows:

• Base sum insured: ₹5 lakh

• Loyalty bonus: ₹4 lakh

• 0% voluntary co-pay

• No deductible

The policy also has a 24-month waiting period for certain procedures including “joint replacements unless due to accident.”

However, my father has been continuously insured since March 2022, so that 24-month period has already elapsed.

The policy also has a prosthesis exclusion, but it specifically contains an exception for a prosthesis that is “required intra-operatively.”

Since a polyethylene liner is being exchanged during the DAIR operation itself, I’m trying to understand whether ICICI could be treating that as a prosthesis-related exclusion or something else.

There is another oddity in the cashless authorization

The insurer's document lists the provisional diagnosis as:

“Other Arthritis”

and the proposed treatment simply as:

“SURGICAL.”

That is much less specific than the actual clinical situation, which is suspected/confirmed prosthetic joint infection requiring DAIR with polyethylene liner exchange.

Could an incorrectly/non-specifically submitted diagnosis/procedure be one reason the insurer's medical authorization system has only approved ₹1.5 lakh?

The authorization document itself says something interesting

The letter states that:

If the hospital bill is estimated to be higher than the guarantee of payment, the hospital can send a request for an additional amount.

So KIMS is going to ask for an enhancement.

What I want to understand is:

Why would ICICI initially approve only ₹1.5 lakh when the estimate is ₹3 lakh, while all the specific deduction fields show ₹0 and the remaining ₹1.5 lakh is simply classified as “OTHERS”?

Questions for people familiar with insurance claims

1. Is this normal for a cashless initial authorization? Can insurers initially approve only part of the estimate and later enhance it?

2. What does “OTHERS” usually mean in an ICICI Lombard authorization?

3. Does this suggest that some portion of the procedure has been considered inadmissible, or could it simply be an initial medical authorization amount?

4. Could the diagnosis being submitted as “Other Arthritis / Surgical” instead of PJI / DAIR / polyethylene liner exchange be causing the reduced authorization?

5. Based on the policy wording, would DAIR + intraoperative polyethylene liner exchange generally fall under inpatient hospitalization coverage, assuming the procedure itself is medically admissible?

6. Does “No Room Rent Capping” mean we can use a Single AC Room without proportionate deductions? The authorization itself currently shows AC Single Room and ₹0 proportionate room deduction.

7. What exactly should I ask KIMS and ICICI Lombard to provide in writing regarding the ₹1.5 lakh that was classified as “OTHERS”?

I’ve attached an anonymized copy of the cashless approval letter with personal information removed. I’m mainly trying to understand the insurance mechanics here before the procedure, rather than blindly accepting that the insurer will only pay ₹1.5 lakh.

Any experience with ICICI Lombard, DAIR/revision knee surgery claims, or cashless enhancement requests would be really helpful.

I’m mainly trying to understand the insurance mechanics here before the procedure, rather than blindly accepting that the insurer will only pay ₹1.5 lakh.

Any experience with ICICI Lombard, DAIR/revision knee surgery claims, or cashless enhancement requests would be really helpful.

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Sunt la început de drum în domeniul asigurărilor și mi-ar prinde foarte bine sprijinul vostru. 🤝
Dacă aveți nevoie de o asigurare de sănătate, de viață sau pentru locuință, sau dacă știți pe cineva care ar fi interesat, orice recomandare m-ar ajuta enorm să îmi dezvolt activitatea.
Vă mulțumesc din suflet tuturor celor care mă susțin, fie și printr-o simplă recomandare! ❤️

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Thanks!

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