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Sub-Limits In Your Health Insurance Policy - See How It Can Affect You

Sub-Limits In Your Health Insurance Policy - See How It Can Affect You

Understanding sub-limits of your health policy is an important thing because not only it helps you to compare between plans to make effective buying health insurance plans decisions but it also helps you to enjoy full benefits our policy because sum-limits actually decides the the percentage of claim that would be settled by your insurer.

Let’s first try and understand what does a sub-limit mean?

Sum-limits mean the extent to which your insurance provider will pay you for certain specific medical expenses when you make a claim. Say for example your existing policy has a sub-limit on doctor’s fee to the extent of 2% of your sum assured for a total policy value is Rs.2 lakhs so technically whatever may be your doctor’s fee you will be always paid to a maximum of Rs.4,000 for it while you make a claim. You should also be very cautious in case of certain expenses like room rent where the sub-limit can become the deciding factor for what would be paid for other specific expenses.


Common sub-limits which are always there are:

  1. Sub limits for specific treatment: To understand this let’s understand the case of Mr. Vijay. Few months back he was admitted to nearest hospital in his city for a gallbladder operation. Since the Vijay was intelligent enough to select the right hospital to get a cash-less  treatment he was able get 100% of the claims settled amounting to Rs.35000 but unfortunately his doctors informed him that the operation was not that much successful because of some pre-existing medical complications and he has to again through an operation within coming two months. But next time when he opted for cashless service for his next operation the TPA told him that approved claim would be only Rs.5000 whereas the actually amount that was charged to Vijay by his hospital was Rs.50000.This is a technically case of sub-limits for specific treatment , Vijay was denied for rest of  Claim because his policy had a sublimit of Rs.40000 for treatment relating to gallbladder            and which he already exhausted during his first operation
  2. Room rent capping: (Room Capping: Is It Something Important While Buying A Online Health Insurance Plan?) Health plans offered by many insurers have common sub-limit which give a right to Insurer Company to pay only a certain percentage of hospital room rent cost. Even before admitting to a hospital you should always check your eligibility under your policy whether you should opt for a single occupancy option or a shared one based on the sub-limit. Say you have a policy of Rs.3 lakh which have a room rent capping of 1.5% on the daily room rent. In case you are admitted in a hospital you should keep in mind that maximum amount of claim which you can get is Rs.4500 per day so you should select things accordingly. In fact this particular capping can also affect claims for other expenses also. Say a policyholder was paid a Rs. 3500 against the actual expense of Rs.5000 because of room rent capping which means that he is been under-paid by 30% then in case of settling for other expenses also the insurance company will settle 70% which would leads to a disastrous effect.
  3. Post-hospitalization sub-limit: Once you are released from your hospital you might might still required some post-hospitalization treatments to recover fully. In this case the insurance providers generally provides for only 30 days of treatment with a limit on the amount that can be claimed under it.

So sum-limits in your health insurance policy are like make or break factor your policy. You should always look at plans without sub-limits so that you enjoy maximum freedom while making a claim. While comparing plans online you should always keep a look on the percentages of these sub-limits. Even if your favourite plan also has certain sub-limits then you always should check on specific sub-limits on certain specific expenses which are necessarily important as your health requirement