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Sub-limits in Health Insurance Policy
Sub-limit is the extent to which an insurer will pay for claims arising from associated medical expenses. Thus, expenses like cost of medicine or cost of surgery will be limited to an amount determined in the sub-limit. For example, the doctor’s fees could be limited to 2% in a health plan worth Rs 2 lakhs.
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- Sub-limits in Health Insurance Policy
The insured will therefore be paid no more than Rs 4,000, even if the doctor’s fees amount to Rs 10,000. When one is purchasing an insurance, one has to be careful about the sub-limits in the policy. Sub-limits are used by insurance companies to reduce their claims outgo.
Sub-limit for specific treatment
Mr Kumar was diagnosed with gallstones and was advised surgery by his physician. He promptly perused the list of hospitals approved by his insurance provider. He approached the one nearest to his residence and submitted the details of his health insurance policy to the third party administrator (TPA) in order to avail cashless treatment.
He was informed that a laproscopy would cost Rs 35,000 and that an approval has been received from the TPA. However, the surgery was a partial success as the doctors could not remove the gall bladder owing to certain complications that Mr Kumar had. The doctors advised him to come back after a month as he would require another surgery.
Mr Kumar approached the TPA and was told that the expenses for the surgery would amount to Rs 50,000. However, the TPA informed him that he would receive an approval for Rs 5,000 only, and he would have to pay the rest out of pocket.
The TPA explained that Mr Kumar’s policy had a provision of Rs 40,000 for this type of treatment. Since the insurer paid Rs 35,000 already, he was entitled to cashless treatment to the extent of the balance amount.
These sub-limits are usually for the more common ailments, like gallstones, kidney stones, piles, sinus, cataracts, etc.
Room rent sub-limit
In most cases, the sub-limit on room rent is the most common one. It is usually limited to a maximum of 1.5% of the sum assured, on a daily basis. These days, hospitals offer various packages depending upon the room type selected.
Thus, a room with double occupancy might cost around Rs 3,000 for a day, while a single occupancy room might set one back by Rs 5,000 for the same duration. So if Mr Vijayhas a policy worth Rs 3 lakhs and it’s specified that per day room rent should not exceed 1.5% of the total amount, he should opt for double occupancy unless he wishes to pay the rest out of pocket.
Additionally, it must be noted that not staying within the sub-limit might adversely affect the policyholder’s claim. The insurance provider will reduce the other sub-limits for the other expenses. In Mr Vijay’s case, if he opts for single occupancy, he exceeds the specified limit by 16.67% and all the sub-limits on associated medical expenses will also be reduced by the same percentage.
Post hospitalization sub-limit
After a policyholder is discharged from the hospital, he/she will incur some post hospitalization expenses. The insurer can introduce a sub-limit to put a ceiling on the amount the insured can claim under such circumstances.
It is always advisable to purchase medical policies that do not have any sub-limits. It might require the policyholder to pay more premium but it results in fewer hassles. That way, during the time of medical emergency, the insured individual will be spared the headache of calculating and spending according to the sub-limits in the policy.
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Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in
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*We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30- minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881.
*Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. Policybazaar does not provide any medical or surgical advice or diagnosis and is not responsible for your interactions / treatment by a medical practitioner/hospital. Please consult a registered medical practitioner for any medical or surgical advice. The Information that you obtain or receive from Policybazaar, and its employees, or otherwise on the Website is for informational purposes only. As per the Insurance guidelines, you are allowed to cancel the policy with-in 30 days from the date of Issuance of policy.This option is available incase of policies with a term of one year or more.
*All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.
**All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws. GST Exemptions depend on fulfilment of qualification criteria and submission of relevant documents.
*₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.
*₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases
*₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases
*₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases
*₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases
*₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.
*₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.
*No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.
*The values taken for effective cost calculation are indicative values and may change as per the selected plan.
*Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.
*Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.
*The scope of coverage may vary from plan to plan.
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