What is a Sub-limit in Health Insurance Policy?

When planning to buy health insurance, certain factors must be considered to opt for the best possible coverage, such as waiting periods, deductibles, and co-payments. However, among all other essential factors, the sub-limit is the most underrated crucial factor in a health insurance policy.

A sub-limit is a pre-decided limitation on the claim amount per different conditions imposed on your health insurance policy by the insurer. Please note that these limits can be placed on hospital room rent, doctor’s consultation fee, ambulance charges, and treatment of certain diseases, such as cataract removal, knee ligament reconstruction, Etc.

To understand the concept of sub-limit in health insurance, keep reading the subtopics below:

Understand the Term Sub-limit for Insurance

The term sub-limits in health insurance is a condition that the insurance provider will pay the expenses of medical issues only up to a specific limit. However, sub-limits will be determined while purchasing a health insurance policy .

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Types of Sub-limits in Health Insurance

A sub-limit is split into three categories. Please note that the list of ailments and cap in treatment costs for various medical conditions may vary from one health insurer to another. Let’s take a look at the key pointers below to understand different types of sub-limits in health insurance.

1. The Ailments Specific Sub-limits

The ailments-specific sub-limits refer to the condition when the insurer sets a coverage limit on the medical expenses of specific diseases, such as cataract surgery, kidney stones, hernia, tonsils, piles, Etc. However, your sum insured amount may be higher, but you cannot claim your entire medical expenses due to the sub-limit clause on some medical practices.

For instance, the insurer has put a sub-limit of INR 60,000 on kidney stone surgery, but the surgery cost is INR 70,000. In that case, the insurer will pay INR 60,000 as per the limit decided, and the policyholders must pay the remaining balance.

It is necessary to check the list of diseases/ailments under the sub-limits clause and the coverage limit specified against each. It’ll help you to know the coverage limit based on a health plan and make an informed decision.

2. Hospital Room Rent Sub-limits

The hospital room rent sub-limits refer to the conditions when the insurer imposes a specific limit on room rent per day coverage. If policyholders opt for a hospital room that exceeds their sub-limit, then the insured person will pay the remaining balance.

However, some insurance providers offer sub-limits caps on room rent, and ICUs are 1% and 2% of the sum insured. It may vary depending on the different room packages.

For instance, if you hold an insurance policy with a sum insured of INR 6 lakhs, you can opt for a hospital room of INR 6,000 per day. In case the hospital room rent exceeds the sub-limit, then you need to pay for the remaining amount from your pocket.

3. Pre & Post-Hospitalization Sub-limits

It is important to note that some health insurance providers also offer sub-limits for pre & post-hospitalization expenses in their health plans. However, after critical surgeries or prolonged hospitalization, it may still require a patient to perform routine checkups after discharge. So, some insurers offer coverage for post-hospitalization expenses by imposing a sub-limit on medical expenses.

Pros and Cons of Sub-limit in Health Insurance

How Do Sub-Limits In Health Insurance Affect Your Claims?

When health insurance policies adopt sub-limits in health insurance policies, the final claim amounts are reduced. Since there are sub-limits on everything from room rent, ICU charges, ambulance charges, Certain ailments and treatments, pre and post-hospitalizations, and other such features insured individuals only file claims within the sub-limits making it easier to approve and provide medical care to customers without the chances of fraudulent claim filing.

What If Sub-limits are Mandatory?

While you can easily find an insurer that offers policies without sub-limits, it may cost you higher premiums. As we know, the sub-limits are pre-decided by the insurer, if you bought the policy with these clauses, you’d be unable to change claim amounts.

In case the sub-limit coverage offered in the policy does not fulfill your specific requirements or cost for healthcare, you can either increase the sum insured or opt for a different insurance provider.

Before making a final decision, look for a policy that fulfills your healthcare needs and fits your budget.

Conclusion

While buying health insurance, understanding sub-limits is quite essential because it can become a factor in determining whether or not a policy fits your requirements. However, comparing the sub-limits of different insurers while selecting the health insurance plan is essential to ensure a stress-free claim process during medical emergencies.

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