Some insurance companies impose a sub-limit on health insurance policies. Due to these, a policyholder may not be allowed to apply for a full claim amount against the health insurance policy. Sub-limits in health insurance reduce the claim amount and increase the out of pocket expenses of the policyholder. If you are trying to learn everything about sub-limits and how it affects health insurance claims, please go through the entire article. The frequently asked questions at the bottom of the page will help resolve some of your queries related to this topic.

What is Sub-Limit in Your Health Insurance Policy? - Acko

What are Sub-Limits in Health Insurance?

Sub-limits in health insurance refer to a condition that the insurer will bear the expenses related to a medical condition only up to a certain limit. The remaining amount of the bill is supposed to be borne by the policyholder. Note that the sub-limit in health insurance is not applicable to the entire bill amount. Under the terms and conditions of the insurance company, sub-limits may only be applicable to certain conditions like room rent or on the treatment of certain diseases.

Example:

Let’s take a look at the sub-limit meaning in health insurance with the help of an example:

  • Mr A had a health insurance policy with sum insured of Rs. 5 Lakh. 
  • The sub-limit on room rent was 1% of the sum insured, i.e. the reimbursement that can be claimed on daily room rent was up to Rs. 5000. 
  • Mr A opted for a twin-sharing deluxe room during his hospital stay that cost Rs 6000 per day. 
  • He made a reimbursement health insurance claim and the insurance company bore Rs. 5000 per day under sub-limit
  • Mr A had to bear the remaining Rs. 1000 per day for the time he was hospitalized.

Different Types of Sub-limits: 

Different types of sub-limits in health insurance include sub-limit on a specific medical condition, sub-limit on room rent, and sub-limit on post-hospitalization charges. Let’s take a look at these three types of sub-limits in detail:

1. Sub-Limit on Specific Disease or Treatment

There are various types of diseases that are so common that 3 in 5 people suffer from them. These include conditions like high blood pressure, pre-planned procedures like plastic-surgery, medical conditions like kidney stone, cataract, piles, gallstone, hernia, tonsils, knee ligament reconstruction, sinus, etc. An insurer puts a sub-limit on treatments for such ailments and procedures. For example, there could be a clause which specifies that an insurer will bear only 80% of the bill or 1% of the sum insured can be used for treatments with sub-limits.

2. Sub-Limit on Hospital Rent

Sub-limit on hospital room rent can be capped at 1% of the sum insured or a fixed sum of money, depending upon the terms and conditions of the insurance company. A medical facility charges separately for a patient’s stay at the hospital. There could be a cap on room rent, doctor’s consultation charges, ICU charges, oxygen supply, ambulance charges, and diagnostic tests.

The patient can choose a room depending upon the comfort and cost of a hospital bed or the room. It is advisable to choose a room that gets fully covered under insurance even with sub-limits. This will help in reducing the out of pocket expenses for medical treatment.

3. Sub Limit on Post Hospitalization 

Major surgeries or prolonged hospitalization may sometimes require a patient to continue treatment even after getting discharged. An insurance company that offers to cover post-hospitalization charges may put a sub-limit on this cost. The policyholder will have to bear the remaining cost if the expenses related to post-hospitalization treatment exceed the coverage.

How To Avoid Or Take Precautions Against Sub-limits?

Sub-limits are decided by the insurance company and the most you can do is thoroughly understand the sub-limits of a policy before making a purchase. You can get in touch with the insurance company and know the sub-limit on each condition. Another thing that you can do is ensure that at least the expenses that are below sub-limits are reimbursed by the health insurance company.

How do Sub-limits Affect Your Claim?

Sub-limits reduce the claim amount. Since there is a cap on specified conditions like room rent, treatment for certain diseases, or post-hospitalization charges, the policyholder can make a claim for only the amount below a sub-limit. If possible, consider the amount of sum insured of your health insurance policy and recheck with the insurance company to confirm that the sub-limit has been extended.

Also, read: Health Insurance for COVID-19

Importance of Sub-Limits in Health Insurance Policy: 

Sub-limits in health insurance are an important factor that will help you evaluate whether the policy fits your requirements. All health insurance policies do not have sub-limits. Some insurers impose a sub-limit on the policy and even give the policyholder an option to opt-in or out of this clause. Note that the premium for a policy with no sub-limits will be slightly higher than the premium for a policy with sub-limits. You should always assess your requirements and budget before purchasing a health insurance plan.  

The sub-limits in online health insurance plans can be found on the insurer’s web portal. Buying a policy online will help reduce its premium as digital insurance companies can afford to pass on the agent commissions and operational costs to the policyholder.

Frequently Asked Questions:

Do all health insurance policies have sub-limits?

No, all health insurance policies do not have a sub-limit clause. Some insurance companies may impose a sub-limit on certain conditions or treatments.

Does IRDA define the amount of sub-limit?

No, there is no defined rule laid down by the IRDA that specifies sub-limits of health insurance

Is there a correct age to buy a health insurance policy?

No, there is no correct age as such to buy a health insurance policy. However, it is wise to buy health insurance as soon as possible. This will help you buy extensive coverage and you can buy a good policy at cheaper rates.

How to check for sub-limits in a health insurance policy?

To check the sub-limit of a health insurance policy simply read the terms and conditions present on the policy document. If you cannot find the sub-limit written on the document, you can get in touch with your insurer and enquire about the same.

Are sub-limits applicable to reimbursement claims?

Yes, sub-limits are applicable to reimbursement claims. These limits are set by the insurance company and are applicable to the claim irrespective of its type. Thus, sub-limits are applicable to both cashless and reimbursement claims.

Which members can be covered with Family-floater health insurance?

The policyholder’s family, i.e. spouse, dependent children, and parents are the members that can be covered with Family-floater health insurance.

Can I buy multiple health insurance policies?

Yes, you can buy multiple health insurance policies. It is a good idea to buy health insurance plans of different types, for example, Individual Health insurance, Critical Illness cover, Family-floater Plans, etc. It will not be wise to invest in similar types of multiple plans.

Are the number of claims capped at a certain number?

No, the number of claims are not capped in health insurance. The policyholder can make multiple claims, however, this can only be done until the sum insured gets exhausted.

Why is it important to renew health insurance in time?

Renewing health insurance in time will help you avail continuous coverage. Also, if no claims are made in the previous policy year, the policyholder can get a discount under the No Claim Bonus discount.

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