One of the key factors to consider before zeroing in on a health insurance policy is sub-limits. Sub-limits lower the insurance premium, but on the flip side they can affect your policy coverage. In this piece, we take a look at sub-limits and how different types can affect your policy coverage.
A sub-limit is a monetary cap that your insurance company puts on the expenses of some medical procedures. It comes as a predetermined limit on the total claim amount, which restricts the insured from applying for a complete claim amount against the health plan. This, in turn, lowers the claim amount.
For instance, sub-limits can be placed on doctor’s consultation fees, ambulance fees, hospital room rents, etc. Hence, you must get in touch with the insurer and understand the sub-limits under each condition before buying any health policy.
Your premium is generally affected by two types of sub-limits, i.e. sub-limits on hospital’s room rent (benefit-specific) and sub-limits on the specific treatment (disease-specific).
When you opt for a room rent sub-limit in the case of hospitalization, your insurer covers the hospital’s room rent. However, this coverage will then be offered up to a certain limit. Moreover, the type of room that you can select is also restricted. Hence, this way sub-limits affect your policy coverage. Some insurers might only cover general or semi-private rooms under this sub-limit. So, if you wish to opt for a private room, you might end up paying the room charges from your pocket.
“For instance, if the room rent is ₹5000 per day and your sub-limit is only ₹3,500, then you would have to pay the remaining ₹1,500 from your pocket. Also, medical expenses would differ depending on the choice of the room. Hence, it is important to read about the sub-limits in the policy document before opting for the plan to avoid any unpleasant surprises during the claim process,” said Rakesh Goyal, director, Probus Insurance.
Benefit-specific sub-limit also includes sub-limits on ambulance fees, domiciliary hospitalization benefit and sub-limits on other benefits such as OPD.
Priya Deshmukh Gilbile, chief operating officer, ManipalCigna Health Insurance, said there are health policies that offer room rent as a percent of the sum insured, while others offer a specific room category or any room without limitations as a percent of the sum insured. Policies that have a capping on room charges may also have optional covers to remove capping or enhance the room category.
“While buying a health insurance policy, it is better to have minimum restrictions even if it costs a little more premium,” said Gilbile.
A disease-specific sub-limit that applies to some common illnesses and pre-planned medical procedures, including kidney stones, knee ligament reconstruction and cataract removal, can also affect your health policy coverage.
“If the policyholder opts for disease-specific sub-limit under the plan, it limits the maximum amount payable per surgery or medical management, cost per policy period for ailments, surgeries and medical procedures as per the option selected by the policyholder under the policy,” said Gilbile.
Goyal added: “Talking about sub-limits on specific treatment/disease, one must make sure to check that the sub-limit clauses are applied to diseases (under your plan) and the costs specified for them. It is not necessary that if your sum insured is higher, you would be able to claim the entire amount.”
Some ailments or diseases may require medical treatment even after discharge. In this case, some insurers might even have sub-limits on the expenses involved in post-hospitalization. The insured would then have to pay this additional amount from his or her pocket, which is not covered under the plan’s post-hospitalization coverage.
Benefit-specific and disease-specific sub-limits differ from insurer to insurer and policy to policy. Also, all insurers might not have sub-limits or similar sub-limits. On the other hand, certain insurers might offer the insured the choice to opt in or out of sub-limits. One must assess one’s medical needs and budgets to avoid any financial burden as the premiums of the policies without sub-limits might be on the higher end. Therefore, it is crucial to check the enlisted diseases or ailments that are under the sub-limit clause and what is the cost specified for each one of them.
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