Most people decide to take up health insurance for protecting themselves as well as their families from unannounced medical emergencies. Health insurance in India includes features like daycare procedures, co-payment clause, cashless cover, etc. Waiting period and exclusions limits imposed by the health insurance provider on payment of the sum assured are some other things that a customer must be aware of before purchasing a plan. An upper limit on the treatment of any medical condition is known as the sub-limits in health insurance plans. It is a monetary limit placed on medical insurance claims by the insurance provider. The same limits are applicable on hospital room rent, ambulance charges, nursing and doctor’s charges, cataract removal, knee replacement charges, etc.

  • Why do you need to know about sub-limits?

A very critical aspect in choosing a health insurance plan is understanding the sub-limits. The lack of unawareness of sub-limits can lead to severe repercussions. You may also be unprepared to meet the costs of medical treatments. Sub-limits can also be mentioned as a fixed value for treating any disease/ illness. It can be expressed as a percentage of sum assured for specific diseases as well. Health Insurance plans with low/ no sub-limits usually have high premiums.

  • Sub-Limit on Room Rent:

The liability of the health insurance policy provider is limited in the room rent sub-limits to a specific amount or percentage of costs related to room expenses. Also, the insurer can restrict the type of room that includes the general room or the semi-private room as well. For instance, if the rent of your room is Rs. 8,000 and the sub-limit of the policy is of Rs. 4,000, then the policyholder will have to fork out Rs. 4,000 from their pockets.

Mostly the medical expenses include doctors and nursing charges. It also includes surgical procedures or the operation theatre charges that also depends on the type of room the policyholder avails. Hence, these expenses will add up to the cost and sub-limit increases the difficulties of the policyholder further. The sub-limit clues need to be discussed by the policyholder with the insurance provider so they are clear and avoid any surprises that are unwanted at the time of claim settlement.

  • Sub-Limit on Specific Treatment:

Before finalizing on any health plan, be it a critical illness insurance policy or health insurance for senior citizens, keeping sub-limit in mind, you must check the list of diseases or conditions that are listed in the sub-limit clause. In addition, check the limit on the costs associated with them. However, claiming the entire amount for treatment or hospitalization is not possible if there is a sub-limit clause, even though the sum you’ve assured is high.

For example; If the sub-limit for the treatment of a particular illness is Rs. 15,00,000 and the sub-limit clause states that in case of that treatment, payment would be made by the health insurer up to 50% of the cost. The insurer would then pay only Rs. 7,50,000 and the remaining amount will have to be paid by the policyholder.

Hence, if you wish to have a claim settlement that is assured and hassle-free, you or whoever is the applicant will need to have a thorough understanding of sub-limit clauses. Therefore, understand the clauses stated in your policy before making an insurance claim.