Every rule, in the open.

# Non-Payable Items — IRDAI Standardised Annexure

IRDAI publishes a standardised list of items insurers do not pay even when they
appear on a hospital bill. The list is identical across every insurer, which is
what makes it safe to evaluate deterministically — no model call per bill line.

Matching is by normalised description (uppercase, punctuation stripped, whitespace
collapsed) against the item names below and their aliases. A bill line matching
nothing here is **escalated to the model**, never silently passed as payable.

## Evaluation order
1. Exact normalised match → classify into its list
2. Alias or substring match → classify, mark `fuzzy: true` for reviewer attention
3. No match → escalate to the model, which must return a list number or `payable`

## Carve-out — consumables riders
Some policies buy back consumables cover. When the Policy Spec carries
`consumables_covered: true`, **List III and List IV become payable** and this rule
must not fire against them. List I and List II are unaffected — those are never
payable regardless of any rider.

## IRDAI-NPI-001 — List I: Items for which coverage is not available in the policy

Never payable under any policy.

**68 items.**

| # | Item | Match key |
|---|---|---|
| 1 | Baby food | `BABY FOOD` |
| 2 | Baby utilities charges | `BABY UTILITIES CHARGES` |
| 3 | Beauty services | `BEAUTY SERVICES` |
| 4 | Belts/ braces | `BELTS BRACES` |
| 5 | Buds | `BUDS` |
| 6 | Cold pack/hot pack | `COLD PACK HOT PACK` |
| 7 | Carry bags | `CARRY BAGS` |
| 8 | Email / internet charges | `EMAIL INTERNET CHARGES` |
| 9 | Food charges (other than patient's diet provided by hospital) | `FOOD CHARGES OTHER THAN PATIENT S DIET PROVIDED BY HOSP` |
| 10 | Leggings | `LEGGINGS` |
| 11 | Laundry charges | `LAUNDRY CHARGES` |
| 12 | Mineral water | `MINERAL WATER` |
| 13 | Sanitary pad | `SANITARY PAD` |
| 14 | Telephone charges | `TELEPHONE CHARGES` |
| 15 | Guest services | `GUEST SERVICES` |
| 16 | Crepe bandage | `CREPE BANDAGE` |
| 17 | Diaper of any type | `DIAPER OF ANY TYPE` |
| 18 | Eyelet collar | `EYELET COLLAR` |
| 19 | Slings | `SLINGS` |
| 20 | Blood grouping and cross matching of donors samples | `BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES` |
| 21 | Service charges where nursing charge also charged | `SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED` |
| 22 | Television charges | `TELEVISION CHARGES` |
| 23 | Surcharges | `SURCHARGES` |
| 24 | Attendant charges | `ATTENDANT CHARGES` |
| 25 | Extra diet of patient (other than that which forms part of bed charge) | `EXTRA DIET OF PATIENT OTHER THAN THAT WHICH FORMS PART ` |
| 26 | Birth certificate | `BIRTH CERTIFICATE` |
| 27 | Certificate charges | `CERTIFICATE CHARGES` |
| 28 | Courier charges | `COURIER CHARGES` |
| 29 | Conveyance charges | `CONVEYANCE CHARGES` |
| 30 | Medical certificate | `MEDICAL CERTIFICATE` |
| 31 | Medical records | `MEDICAL RECORDS` |
| 32 | Photocopies charges | `PHOTOCOPIES CHARGES` |
| 33 | Mortuary charges | `MORTUARY CHARGES` |
| 34 | Walking aids charges | `WALKING AIDS CHARGES` |
| 35 | Oxygen cylinder (for usage outside the hospital) | `OXYGEN CYLINDER FOR USAGE OUTSIDE THE HOSPITAL` |
| 36 | Spacer | `SPACER` |
| 37 | Spirometre | `SPIROMETRE` |
| 38 | Nebulizer kit | `NEBULIZER KIT` |
| 39 | Steam inhaler | `STEAM INHALER` |
| 40 | Armsling | `ARMSLING` |
| 41 | Thermometer | `THERMOMETER` |
| 42 | Cervical collar | `CERVICAL COLLAR` |
| 43 | Splint | `SPLINT` |
| 44 | Diabetic foot wear | `DIABETIC FOOT WEAR` |
| 45 | Knee braces (long/ short/ hinged) | `KNEE BRACES LONG SHORT HINGED` |
| 46 | Knee immobilizer/shoulder immobilizer | `KNEE IMMOBILIZER SHOULDER IMMOBILIZER` |
| 47 | Lumbo sacral belt | `LUMBO SACRAL BELT` |
| 48 | Nimbus bed or water or air bed charges | `NIMBUS BED OR WATER OR AIR BED CHARGES` |
| 49 | Ambulance collar | `AMBULANCE COLLAR` |
| 50 | Ambulance equipment | `AMBULANCE EQUIPMENT` |
| 51 | Abdominal binder | `ABDOMINAL BINDER` |
| 52 | Private nurses charges- special nursing charges | `PRIVATE NURSES CHARGES SPECIAL NURSING CHARGES` |
| 53 | Sugar free tablets | `SUGAR FREE TABLETS` |
| 54 | Creams powders lotions (toiletries are not payable, only prescribed medical pharmaceuticals payable) | `CREAMS POWDERS LOTIONS TOILETRIES ARE NOT PAYABLE ONLY ` |
| 55 | Ecg electrodes | `ECG ELECTRODES` |
| 56 | Gloves | `GLOVES` |
| 57 | Nebulisation kit | `NEBULISATION KIT` |
| 58 | Any kit with no details mentioned [delivery kit, orthokit, recovery kit, etc] | `ANY KIT WITH NO DETAILS MENTIONED DELIVERY KIT ORTHOKIT` |
| 59 | Kidney tray | `KIDNEY TRAY` |
| 60 | Mask | `MASK` |
| 61 | Ounce glass | `OUNCE GLASS` |
| 62 | Oxygen mask | `OXYGEN MASK` |
| 63 | Pelvic traction belt | `PELVIC TRACTION BELT` |
| 64 | Pan can | `PAN CAN` |
| 65 | Trolly cover | `TROLLY COVER` |
| 66 | Urometer, urine jug | `UROMETER URINE JUG` |
| 67 | Ambulance | `AMBULANCE` |
| 68 | Vasofix safety | `VASOFIX SAFETY` |

## IRDAI-NPI-002 — List II: Items that are to be subsumed into Room Charges

Payable only as part of room rent. A separate line is a duplicate charge.

**37 items.**

| # | Item | Match key |
|---|---|---|
| 1 | Baby charges (unless specified/indicated) | `BABY CHARGES UNLESS SPECIFIED INDICATED` |
| 2 | Hand wash | `HAND WASH` |
| 3 | Shoe cover | `SHOE COVER` |
| 4 | Caps | `CAPS` |
| 5 | Cradle charges | `CRADLE CHARGES` |
| 6 | Comb | `COMB` |
| 7 | Eau-de-cologne / room freshners | `EAU DE COLOGNE ROOM FRESHNERS` |
| 8 | Foot cover | `FOOT COVER` |
| 9 | Gown | `GOWN` |
| 10 | Slippers | `SLIPPERS` |
| 11 | Tissue paper | `TISSUE PAPER` |
| 12 | Tooth paste | `TOOTH PASTE` |
| 13 | Tooth brush | `TOOTH BRUSH` |
| 14 | Bed pan | `BED PAN` |
| 15 | Face mask | `FACE MASK` |
| 16 | Flexi mask | `FLEXI MASK` |
| 17 | Hand holder | `HAND HOLDER` |
| 18 | Sputum cup | `SPUTUM CUP` |
| 19 | Disinfectant lotions | `DISINFECTANT LOTIONS` |
| 20 | Luxury tax | `LUXURY TAX` |
| 21 | Hvac | `HVAC` |
| 22 | House keeping charges | `HOUSE KEEPING CHARGES` |
| 23 | Air conditioner charges | `AIR CONDITIONER CHARGES` |
| 24 | Im iv injection charges | `IM IV INJECTION CHARGES` |
| 25 | Clean sheet | `CLEAN SHEET` |
| 26 | Blanket/warmer blanket | `BLANKET WARMER BLANKET` |
| 27 | Admission kit | `ADMISSION KIT` |
| 28 | Diabetic chart charges | `DIABETIC CHART CHARGES` |
| 29 | Documentation charges / administrative expenses | `DOCUMENTATION CHARGES ADMINISTRATIVE EXPENSES` |
| 30 | Discharge procedure charges | `DISCHARGE PROCEDURE CHARGES` |
| 31 | Daily chart charges | `DAILY CHART CHARGES` |
| 32 | Entrance pass / visitors pass charges | `ENTRANCE PASS VISITORS PASS CHARGES` |
| 33 | Expenses related to prescription on discharge | `EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE` |
| 34 | File opening charges | `FILE OPENING CHARGES` |
| 35 | Incidental expenses / misc. Charges (not explained) | `INCIDENTAL EXPENSES MISC CHARGES NOT EXPLAINED` |
| 36 | Patient identification band / name tag | `PATIENT IDENTIFICATION BAND NAME TAG` |
| 37 | Pulseoxymeter charges | `PULSEOXYMETER CHARGES` |

## IRDAI-NPI-003 — List III: Items that are to be subsumed into Procedure Charges

Payable only as part of the procedure. A separate line is a duplicate charge.

**23 items.**

| # | Item | Match key |
|---|---|---|
| 1 | Hair removal cream | `HAIR REMOVAL CREAM` |
| 2 | Disposables razors charges (for site preparations) | `DISPOSABLES RAZORS CHARGES FOR SITE PREPARATIONS` |
| 3 | Eye pad | `EYE PAD` |
| 4 | Eye sheild | `EYE SHEILD` |
| 5 | Camera cover | `CAMERA COVER` |
| 6 | Dvd, cd charges | `DVD CD CHARGES` |
| 7 | Gause soft | `GAUSE SOFT` |
| 8 | Gauze | `GAUZE` |
| 9 | Ward and theatre booking charges | `WARD AND THEATRE BOOKING CHARGES` |
| 10 | Arthroscopy and endoscopy instruments | `ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS` |
| 11 | Microscope cover | `MICROSCOPE COVER` |
| 12 | Surgical blades, harmonicscalpel,shaver | `SURGICAL BLADES HARMONICSCALPEL SHAVER` |
| 13 | Surgical drill | `SURGICAL DRILL` |
| 14 | Eye kit | `EYE KIT` |
| 15 | Eye drape | `EYE DRAPE` |
| 16 | X-ray film | `X RAY FILM` |
| 17 | Boyles apparatus charges | `BOYLES APPARATUS CHARGES` |
| 18 | Cotton | `COTTON` |
| 19 | Cotton bandage | `COTTON BANDAGE` |
| 20 | Surgical tape | `SURGICAL TAPE` |
| 21 | Apron | `APRON` |
| 22 | Torniquet | `TORNIQUET` |
| 23 | Orthobundle, gynaec bundle | `ORTHOBUNDLE GYNAEC BUNDLE` |

## IRDAI-NPI-004 — List IV: Items that are to be subsumed into costs of treatment

Payable only as part of treatment cost. A separate line is a duplicate charge.

**18 items.**

| # | Item | Match key |
|---|---|---|
| 1 | Admission/registration charges | `ADMISSION REGISTRATION CHARGES` |
| 2 | Hospitalisation for evaluation/ diagnostic purpose | `HOSPITALISATION FOR EVALUATION DIAGNOSTIC PURPOSE` |
| 3 | Urine container | `URINE CONTAINER` |
| 4 | Blood reservation charges and ante natal booking charges | `BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGE` |
| 5 | Bipap machine | `BIPAP MACHINE` |
| 6 | Cpap/ capd equipments | `CPAP CAPD EQUIPMENTS` |
| 7 | Infusion pump– cost | `INFUSION PUMP COST` |
| 8 | Hydrogen peroxide\spirit\ disinfectants etc | `HYDROGEN PEROXIDE SPIRIT DISINFECTANTS ETC` |
| 9 | Nutrition planning charges - dietician charges- diet charges | `NUTRITION PLANNING CHARGES DIETICIAN CHARGES DIET CHARG` |
| 10 | Hiv kit | `HIV KIT` |
| 11 | Antiseptic mouthwash | `ANTISEPTIC MOUTHWASH` |
| 12 | Lozenges | `LOZENGES` |
| 13 | Mouth paint | `MOUTH PAINT` |
| 14 | Vaccination charges | `VACCINATION CHARGES` |
| 15 | Alcohol swabes | `ALCOHOL SWABES` |
| 16 | Scrub solution/sterillium | `SCRUB SOLUTION STERILLIUM` |
| 17 | Glucometer& strips | `GLUCOMETER STRIPS` |
| 18 | Urine bag | `URINE BAG` |

## Aliases seen on real bills

Hospital billing systems abbreviate. These map onto the items above and are
applied before fuzzy matching.

| Alias on bill | Maps to |
|---|---|
| `REGN FEE`, `REGISTRATION`, `MRD CHARGES` | Admission/registration charges (List IV) |
| `GLOVES`, `STERILE GLOVES` | Gloves (List III) |
| `SPIRIT`, `BETADINE`, `SAVLON` | Hydrogen peroxide/spirit/disinfectants (List IV) |
| `TV CHARGES`, `TELEVISION` | Television charges (List I) |
| `ATTENDER FOOD`, `VISITOR MEAL` | Food charges other than patient diet (List I) |
| `LAUNDRY`, `LINEN` | Laundry charges (List I) |
| `N95`, `FACE MASK` | Mask (List III) |

Extend this table rather than editing the verbatim lists above — those are a
faithful copy of the regulator's annexure and should stay that way.

# Room Rent Limit and Proportionate Deduction

## IRDAI-RR-001 — Room rent eligibility
The policy defines an eligible room rent, usually as a percentage of sum insured
(commonly 1% per day for a normal room, 2% for ICU) or as an absolute per-day cap.

```
eligible_room_rent = policy.room_rent_limit_pct * policy.sum_insured
                     OR policy.room_rent_limit_absolute
```

If `actual_room_rent <= eligible_room_rent`, no deduction. Stop here.

## IRDAI-RR-002 — Proportionate deduction
When the member occupies a room above their eligible category, the insurer scales
down room-linked charges by the same ratio.

```
payable_ratio = eligible_room_rent / actual_room_rent

deduction = (1 - payable_ratio) * sum(room_linked_charges)
```

### Worked example
Eligible ₹5,000/day, actual ₹7,000/day, 4 days.

```
payable_ratio = 5000 / 7000 = 0.7143

Room rent      ₹28,000 → payable ₹20,000  (capped at eligible, not scaled)
Doctor visits  ₹12,000 → payable ₹ 8,571
Surgeon fee    ₹40,000 → payable ₹28,572
Nursing        ₹ 8,000 → payable ₹ 5,714
```

## IRDAI-RR-003 — What proportionate deduction applies to
**Applies to** — room-linked charges only:
- Room rent
- Doctor / consultant visit fees
- Surgeon and anaesthetist fees
- Nursing charges
- Operation theatre charges

**Does NOT apply** (IRDAI Master Circular, 29 May 2024 — this is the change most
systems get wrong, and applying it produces an over-deduction the member can
successfully dispute):
- ICU charges
- Medicines and drugs
- Implants and prosthetics
- Consumables
- Diagnostics and investigations

Any adjudication that scales medicines, implants, diagnostics or ICU by the room
ratio is applying a rule that was repealed in 2024. Flag it.

## IRDAI-RR-004 — ICU has its own limit
ICU room rent is governed by `policy.icu_limit`, evaluated independently of the
normal room rent limit. Exceeding the ICU limit caps the ICU charge but — per
RR-003 — does not trigger proportionate deduction on anything else.

## IRDAI-RR-005 — No room rent limit
If the Policy Spec has `room_rent_limit: null` or the policy states "no room rent
capping" / "any room category", this entire rule family is inert. Do not deduct.
Single private room restrictions may still apply — check `room_category_limit`.

# Regulatory Timelines (IRDAI Master Circular, 29 May 2024)

This circular repealed 55 prior circulars and consolidated policyholder
entitlements. These are obligations **on the insurer**, so they do not block a
claim — but a claim approaching one of these boundaries is worth surfacing.

## IRDAI-TIME-001 — Cashless authorisation: 1 hour
The insurer must decide on a cashless authorisation request within **1 hour** of
receiving it.

## IRDAI-TIME-002 — Cashless discharge: 3 hours
The insurer must finalise a cashless claim within **3 hours** of receiving the
discharge request from the hospital. Infrastructure was mandated in place by
31 July 2024.

## IRDAI-TIME-003 — Treatment dates within policy period
Deterministic and genuinely blocking.

```
if admission_date < policy.start_date OR discharge_date > policy.end_date
   → BLOCKER
```

Watch the boundary case: admission inside the period, discharge after expiry. Most
policies cover the full episode if admission was within the period — check the
policy clause rather than assuming.

# Waiting Periods and Moratorium

Requires judgement — mapping a diagnosis to a waiting-period category is not a
string match. The model must cite the policy clause it relied on.

## IRDAI-WP-001 — Initial waiting period
30 days from policy inception. Illness claims within this window are not payable.
**Accidents are exempt** — an accidental injury claim on day 3 is valid.

```
if (admission_date - policy.start_date) < 30 days
   AND diagnosis is not accident-related
   → BLOCKER
```

## IRDAI-WP-002 — Pre-existing disease (PED)
Maximum PED waiting period is **36 months** (reduced from 48). A policy stating a
longer PED waiting period is non-compliant — flag it as an advisory against the
policy itself, not against the claim.

A pre-existing disease is any condition diagnosed by a physician within **48 months
prior** to the effective date of the first policy issued by that insurer to the member.

Group policies commonly waive PED entirely. Check `policy.ped_waiting_months`
before firing — a waiver is the common case in corporate cover, and a false PED
rejection is the most damaging error this system can make.

## IRDAI-WP-003 — Specific disease / procedure waiting period
Typically 24–36 months in retail policies for named conditions — cataract, hernia,
joint replacement, kidney stones, piles, sinusitis. **Often waived in group plans.**
Read `policy.specific_waiting_periods[]` from the Policy Spec; do not assume the
retail default applies to a corporate policy.

## IRDAI-WP-004 — Maternity waiting period
Retail: 9–24 months. Group plans typically waive or reduce this to immediate cover.

## IRDAI-WP-005 — Moratorium (60 months)
After **60 months** of continuous coverage, a claim cannot be rejected on grounds
of non-disclosure or misrepresentation — only established fraud remains grounds.

If the member has ≥60 months continuous cover, any finding based on non-disclosure
must be suppressed and replaced with an advisory noting the moratorium applies.

# Bill Arithmetic

Pure computation. Free, instant, and it catches both extraction errors and genuine
billing errors — which is why a failure here must be shown with the source page
image, not just asserted.

## COM-CALC-001 — Line items sum to bill total
```
abs(sum(line_items.amount) - bill.total) <= 1.00   # rupee rounding
```
A mismatch is either a bad extraction or a real billing error. Show the extracted
lines beside the bill image and let the reviewer decide which.

## COM-CALC-002 — Claimed amount does not exceed bill total
`claimed_amount > bill.total` → `deficiency`.

## COM-CALC-003 — Room rent line reconciles with stay length
```
room_rent_total ÷ room_rent_per_day ≈ (discharge_date - admission_date) in days
```
A mismatch means either the bill days or the discharge summary dates are wrong.
Cross-reference COM-ID-004.

## COM-CALC-004 — Sum insured balance
`claimed_amount > policy.sum_insured_remaining` → `advisory` with the payable
capped at the remaining balance. Not a blocker: a partial payout is still valid.

## COM-CALC-005 — Sub-limit breach
Where the policy defines a procedure sub-limit (cataract, maternity, hernia), a
claim exceeding it is capped at the sub-limit. `deduction`, and cite the clause.

# Document Completeness

Missing discharge summaries, illegible bills and absent investigation reports are
the documented top causes of a claim entering "query" status. Every one of them is
detectable before submission.

## COM-DOC-001 — Baseline reimbursement document set (IPD)
Required for every insurer and TPA:

| Document | Notes |
|---|---|
| Claim form Part A | Signed by the insured |
| Claim form Part B | Signed and stamped by the treating hospital |
| Discharge summary | Must state complaints, diagnosis, treatment given, dates |
| Final hospital bill | Itemised, not just a total |
| Payment receipts | Proof the member actually paid |
| Investigation reports | Every report referenced in the bill or discharge summary |
| Doctor's prescriptions | For pharmacy line items |
| KYC / ID proof | Photo ID of the patient |

Absence of any → `blocker`.

## COM-DOC-002 — Itemised bill required
A bill showing only a total is not adjudicable — non-payable items cannot be
identified and room rent cannot be separated. `blocker`.

## COM-DOC-003 — Legibility
Any page whose triage legibility score falls below threshold is a `deficiency`
before it ever reaches extraction. Return it to the member for a rescan rather
than guessing at the numbers.

## COM-DOC-004 — Investigation report referenced but not attached
If the bill or discharge summary references an investigation (X-ray, CT, MRI,
blood panel) and no matching report document was uploaded → `deficiency`.
This is the check that catches the single most common query in practice.

## COM-DOC-005 — Duplicate page
The same page uploaded twice is usually a symptom that a different, required page
is missing. `advisory`, and re-run COM-DOC-001 to say which.

## COM-DOC-006 — Document type does not match its claimed content
Triage classifies each page independently of its filename. A page uploaded as
"discharge_summary.pdf" that is actually an X-ray image is a `deficiency` —
and this is where the "is it even an X-ray" check lives.

# Cross-Document Identity Consistency

Discrepancies between hospital paperwork and policy records — name, date of birth,
member ID — are among the most common causes of a TPA query, and they are fully
deterministic. No model is needed. This is the cheapest high-value check in the
system, so it runs first.

The comparison is across every extracted document: claim form ↔ discharge summary
↔ hospital bill ↔ ID card ↔ Policy Spec.

## COM-ID-001 — Patient name mismatch
Normalise before comparing: uppercase, strip titles (Mr/Mrs/Ms/Dr/Master/Baby of),
collapse whitespace, strip punctuation.

- Exact match after normalisation → pass
- Levenshtein distance ≤ 2, or one string is a subset of the other (initials vs
  expanded middle name) → `advisory`, show both spellings
- Otherwise → `deficiency`

Common false positive: Indian names legitimately appear as "SURESH KUMAR R" on one
document and "R SURESH KUMAR" on another. Token-set comparison, not string
comparison.

## COM-ID-002 — Member / policy / UHID mismatch
Exact match required after stripping spaces and hyphens. Any mismatch is a
`deficiency` — this is what the TPA matches on, and a wrong ID means the claim is
attached to the wrong person.

## COM-ID-003 — Date of birth mismatch
Exact match required across all extracted documents.

- Three or more documents carry a DOB and all but one agree → `advisory`, naming
  the outlier document explicitly (e.g. "discharge summary states 12-03-1978;
  claim form, ID proof and Policy Spec state 12-03-1979"). A lone outlier against
  a clear majority is a transcription slip at source, not an identity mismatch.
- Otherwise (no majority, or only two documents carry a DOB and they disagree) →
  `deficiency`. A one-year or transposed-digit difference here is the most common
  real instance and TPAs reject on it.

## COM-ID-004 — Admission / discharge date disagreement
Admission and discharge dates must agree between the discharge summary, the
hospital bill and the claim form.

A bill covering more days than the discharge summary states is a `deficiency` and
also inflates the room rent calculation — flag both.

## COM-ID-005 — Patient is not a covered member
The patient must appear in the policy's covered members (self, spouse, children,
parents per `policy.coverage_type`). A claim for a relation the policy does not
cover — e.g. parents under an `es` (employee + spouse) policy — is a `blocker`.

# Consolidated Bill Head With No Break-up

## Why this rule exists

This is one of the most common real deductions and it is entirely invisible to a
member until the money is gone. Verbatim from deduction prose on settled claims:

- `Rs.25221 Medicine Cost wish Breakup`
- `Rs.15000 Cost wise Breakup`
- `medicine brakup not given-8900`
- `Rs.1120 Lab Cost wish Breakup`
- `Rs.350/- Investigation - Deducted as Cost wise break up not furnished`

The shape never varies. The hospital bills one large line called `Pharmacy` or
`Investigations` with no description, quantity or rate behind it; the insurer
disallows the entire unitemised amount. It is a documentation failure with a
very large price tag, and it is fully detectable before submission — which is
precisely what this product is for.

## COM-DOC-006 — a line that names a category, not a thing

A bill line is consolidated when it is a category head rather than an item. Two
shapes qualify:

1. **An explicit deferral** — the description itself admits the detail is
   elsewhere: "as per detail enclosed", "cost wise breakup", "as per attached".
   Conclusive at any shape.
2. **A bare head** — the description reduces to nothing but a category word
   (`PHARMACY`, `INVESTIGATIONS`, `MISCELLANEOUS`, `PACKAGE`, `CONSUMABLES`,
   `SUNDRY`, `OTHERS`) once filler like "charges" or "total" is removed.

`PHARMACY` qualifies. `PHARMACY - INJ CEFTRIAXONE 1G` does not: the drug is
named, so the line is itemised.

### Thresholds

Only lines of **₹5,000 or more** are raised. A ₹200 line called "Pharmacy" is a
rounding artefact, not a documentation failure worth a reviewer's attention;
₹5,000 is where insurers in the sampled data actually began disallowing.

A line carrying a real quantity **and** a rate is treated as itemised, because
that arithmetic is itself the break-up.

### Scoring

Points scale with exposure rather than sitting flat, because a reviewer
triaging a queue needs the size of the problem to show in the ranking:

| Unitemised total | Points |
|---|---|
| ₹20,000 and above | 12 |
| ₹10,000 – ₹19,999 | 8 |
| ₹5,000 – ₹9,999 | 6 |

### Fix

Ask the hospital billing counter for the item-wise break-up — description,
quantity and rate per line — and attach it before submitting. This is usually
the cheapest deficiency on a claim to fix and the most expensive to ignore.

# Unknown / Unmapped Partner — Default Behaviour

## TPA-DEFAULT-001 — No rule file for this partner
When a claim names a TPA with no file in `rulebook/tpa/`, ClaimShield applies only
the IRDAI and common rules and emits an `advisory` saying so explicitly.

It must never imply the claim passed partner-specific checks that were never run.
The advisory reads:

> No partner rule file exists for **{tpa}**. IRDAI and cross-document checks were
> applied; partner-specific document and timeline requirements were **not**
> checked. Add `rulebook/tpa/{tpa}.md` to enable them.

This is the honest failure mode, and it doubles as the prompt that grows the
rulebook — an unmapped partner appearing repeatedly in the dashboard is the
signal that its rule file is worth writing.

## TPA-DEFAULT-002 — Conservative fallback timelines
Absent a partner file, apply the tightest commonly observed windows as advisories
only, never as deficiencies:
- Intimation: 48 hours from admission
- Document submission: 15 days from discharge

# ICICI Lombard — Partner Requirements

## IL-TIME-001 — Documents within 30 days of discharge
All claim documents must be submitted **in original within 30 days from the date
of discharge**.

```
if (submission_date - discharge_date) > 30 days → deficiency
```

## IL-DOC-001 — Originals required
ICICI Lombard requires originals, not photocopies, for: the claim form, the
discharge summary and the final hospital bill. A scan is acceptable for preflight
review but the physical originals must follow — `advisory`.

## IL-DOC-002 — Document ordering
Documents must be arranged in sequence: original bill, X-ray reports, medical
expenses, discharge summary, other hospital bills. Out-of-order submissions are
returned. `advisory` — ClaimShield can emit the correct order rather than just
flag it.

## IL-DOC-003 — Claim form signatures
The claim form must be signed by **both** the insured and the treating doctor.
An unsigned doctor section is a `deficiency` — detectable from the form image.

## IL-NOTIF-001 — Notification of hospitalisation
The policyholder must notify ICICI Lombard of the hospitalisation. Absence of a
notification reference on the claim is an `advisory`.

# Medi Assist — Partner Requirements

India's largest health benefits administrator. Timelines here are tighter than
most, and the 48-hour intimation window is the one claims miss.

## MA-TIME-001 — Intimation within 48 hours of admission
Reimbursement claims must be intimated within **48 hours from the date of
admission**. Late intimation is a documented cause of rejection.

```
if (intimation_datetime - admission_datetime) > 48 hours → deficiency
```

## MA-TIME-002 — Documents within 30 days of discharge (group policies)
For **group / corporate** policies, claim documents must be submitted within
**30 days from the date of discharge**, per the Medi Assist portal FAQ and the
corporate circular. Retail / individual policies remain at **15 days** until the
retail window is confirmed against a Medi Assist source.

```
limit_days = 30 if policy.is_group else 15
if (submission_date - discharge_date) > limit_days → deficiency
```

## MA-DOC-001 — Mandatory intimation fields
All of the following must be present at intimation:

| Field |
|---|
| Employee number |
| Name of company |
| Mediclaim card number |
| Employee name |
| Patient name and relation to employee |
| Name and address of hospital |
| Date of admission |
| Diagnosis details |
| Contact number |
| Email ID |

Any missing field → `deficiency`, named individually so the fix is unambiguous.

## MA-DOC-002 — Non-network hospital additional documents
For a non-network hospital, cashless requests additionally require KYC documents
and a brief MOU. Without them the cashless request cannot be authorised → `blocker`
for cashless; does not affect reimbursement.

# Paramount TPA — Partner Requirements

Paramount administers claims for several insurers (Care Health, Future Generali,
United India, Oriental, Royal Sundaram, Reliance General) and **publishes a
different claim form per insurer**. The correct form is a function of the insurer,
not of the TPA.

## PTPA-TIME-001 — Documents within 15 days
Hospitals must submit the entire claim document set within **15 days**.

## PTPA-DOC-001 — Insurer-specific claim form
The claim form must be the variant Paramount publishes for that insurer. A Care
Health form submitted on an Oriental Insurance policy is returned.

| Insurer | Form |
|---|---|
| Care Health | Health_Claim_Form.pdf |
| Future Generali | FutureGeneraliClaimForm.pdf |
| United India | HEALTH_CLAIM_FORM(1).pdf |
| Oriental Insurance | Health Claim Form Part-A / Part-B |
| Royal Sundaram | Health claim form.pdf |
| Reliance General | Health_(TPA)_Claim_FormB.pdf |

Wrong variant → `deficiency`.

## PTPA-DOC-002 — No document deficiency at submission
Paramount runs post-claim scrutiny and returns anything incomplete against its own
checklist. Submitting a known-incomplete set guarantees a query round-trip —
which is precisely what ClaimShield exists to prevent.