Sub Limits in Your Health Insurance

What are Sub-limits in Health Insurance?

A sub-limit is an extra limit to a health insurance policy coverage placed on certain medical expenses. These medical expenses are covered as a part of the original policy coverage limit, that is the sum insured. Your insurance company can limit its liability under specific covers by including sub-limits.

In simpler terms, a sub-limit is a monetary cap that your insurance service provider places on your medical insurance claim for certain covers. They are usually expressed as a fixed value for a particular illness/disease/treatment but can also be included as a percentage of the total sum insured.

Sub-limits can be placed on hospital room rent, doctor's consultation fee, ambulance charges, and a few pre-planned medical procedures, such as cataract removal, knee ligament reconstruction, etc.

Importance of a Sub-limit in a Health Insurance Policy

A sub-limit is one of the critical features to evaluate in health insurance. Health insurance plans without sub-limits may cost you more as the plans with sub-limits are comparatively affordable. This happens because the liability of an insurance company reduces with the help of a sub-limit.

In case you need basic medical insurance coverage and don't want to spend a lot on premiums, then you must opt for a health plan with sub-limits.

Disadvantages of Sub-limits in a Health Insurance Policy

A health insurance plan without sub-limits allows you to avail coverage up to the sum insured limit. You do not need to check that the medical expenses, such as room rent and ambulance charges, are within the reimbursable limit of the policy before getting treated in a hospital.

Thus, you must decide to either buy a health insurance policy with sub-limits or without sub-limits as per your budget and health coverage needs.

Types of Sub-limits in Health Insurance

Most health insurance providers place three kinds of sub-limits on a health insurance policy i.e. on the hospital room rent, the sum insured for specific diseases and post-hospitalisation expenses. Some companies also provide the policyholder with the option to opt for or opt out of sub-limits.

Let's understand the three key types of sub-limits in health insurance so that you can make an informed decision:

1. Sub-limit on Room Rent

   Under the room rent sub-limit option, your health insurance company covers the hospital room rent per day but only up to a certain limit. If you opt for a room with a daily rent of more than your sub-limit, then you will have to pay the additional charges.

   For example, if the room rent cap in your health insurance plan is ₹4000 per day and you opt for a room that costs ₹6000 per day, you will have to pay the difference of ₹ 2000 from your pocket.

   The type of hospital room can also be capped under this type sub-limit. This happens because the hospitalization charges are also linked with the type of room you opt for. Most of the medical expenses, such as surgical procedures, doctor's consultation charges, operation theatre fees, etc., may vary depending on the type of hospital room you are staying in.

   For instance, the insurer may include only the general room or twin-sharing room in its mediclaim insurance plans. If you need a private room, then you may have to pay an extra premium for it. This can happen because a twin-sharing room or a general room may cost less as compared to a private room.

2. Sub-limit on Specific Treatments

   Under the specific treatment sub-limits, health insurance companies places a coverage limit on the total treatment cost of specific diseases. Even though your sum insured may be high, you will not be able to claim your entire hospitalization expenses due to the sub-limit clause on specific medical procedures.

   For instance, suppose your health policy comes with a sub-limit of 50% of the sum insured for cancer treatment. In this case, even if your total sum insured is ₹10 lakh, you cannot claim more than ₹5 lakh for cancer treatment due to the sub-limit clause.

   Before you decide to buy a health policy with a sub-limit on the specific treatment, you must check the list of diseases/ailments which come under the sub-limits clause and the coverage limit specified against each of them. It will help you to be aware of the sub-limits under a health plan and make an informed decision about buying it.

3. 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.

Summing It Up

Sub-limits are an important feature to keep in mind while buying a health insurance policy. The decision to buy a health plan with sub-limits depends on your preference and budget. If you want to make your hospitalization and claim procedure hassle-free, then it is important to go through the sub-limit clauses under a health plan and opt for it only if it meets your budget and coverage needs.