Admitted Just for an MRI? Why Your Health Insurance Claim Will Be Rejected

🛑 The "Free MRI" Scam

Your doctor suggests an MRI scan that costs ₹15,000. You hesitate to pay from your pocket. So, you ask the hospital: "Can you admit me for 24 hours so I can claim this from my insurance?" The hospital agrees. You get admitted, sleep in the AC room, get the MRI, and go home.

Result: Claim Rejected. You now owe the hospital ₹15,000 for the MRI + ₹10,000 for the room rent. Why? Because you violated the standard IRDAI exclusion clause regarding "Evaluation & Investigation."

Admitted Just for an MRI?

Health insurance in India is fundamentally designed to cover Hospitalization for Treatment, not for Diagnosis.

In 2026, AI-driven claim processing by TPAs (Third Party Administrators) instantly flags admissions where the primary billing code is diagnostic (MRI, CT, Endoscopy) without corresponding "Active Treatment" codes (Surgery, IV infusions).

The IRDAI Rule (No Cure, No Pay)

According to IRDAI regulations, an inpatient hospitalization claim is valid only if it satisfies specific criteria:

✅ The Validity Checklist:

• The admission involves an "Active Line of Treatment" (e.g., IV antibiotics, monitoring of unstable vitals, surgical intervention).
• The treatment required is of such a nature that it could not have been carried out on an OPD basis.
• Red Flag: If the doctor only prescribed oral tablets (painkillers, antacids) after the MRI, the claim will be 100% rejected. Oral medication does not justify a hospital bed.

When DOES Insurance Pay for MRI?

Does this mean insurance never pays for scans? No. They pay in these specific scenarios:

Scenario	Outcome
Admitted ONLY for MRI	Rejected (Investigation Only)
Admitted for Surgery (MRI done 2 days prior)	Approved (Covered under 'Pre-Hospitalization' expenses, usually 30-60 days before admission).
You have 'OPD Cover' Add-on	Approved (Claimable up to your specific OPD wallet limit).

Key Takeaway: The MRI cost is only reimbursable if it leads to a hospitalization for a specific treatment. If the MRI shows "All Normal" and you go home, the cost is yours to bear.

Chief Editor’s Verdict

Do not attempt to outsmart the insurer's medical team. They review thousands of these "fake admission" claims daily and will spot the pattern immediately.

If you want diagnostic tests covered, purchase a policy with a dedicated OPD (Out-Patient Department) Rider (such as plans from Niva Bupa, Star Health, or ICICI Lombard). It costs slightly more, but it legitimately pays for diagnostics without the need for a hospital bed.

⚖️ Legal Disclaimer:
The information provided in this article is for educational purposes only and does not constitute insurance or legal advice. Insurance policies in India are subject to IRDAI regulations and specific policy terms (Policy Wordings). Clauses regarding "Investigation & Evaluation" (Code-Excl04) vary by insurer. Always read your policy document or consult a licensed insurance advisor before filing a claim.