When you look for a health insurance policy, there are a lot of extra features to consider apart from its coverage, such as deductibles, co-payments, or waiting periods. Another such feature to keep in mind in health insurance is sub-limits.

A sub-limit is a predetermined monetary cap that is placed on your claim amount by the insurer. However, it is important to note that the sub-limit in health insurance won’t be applicable to the entire bill amount, but rather to certain conditions. These limits can be placed on hospital room rent, treatment of certain diseases, ambulance charges, and more.

In some cases, this sub-limit may be calculated as a percentage of your sum insured. For example, if your SI is ₹5 lakh room, and your rent charges are capped at 1%, your insurance will cover the same up to ₹5,000.

Sub-limits are put in place by insurance companies to decrease their overall claims. As they are usually set at the average rates charged by most hospitals, it can also reduce instances of fraud and inflated medical bills by customers.

All health insurance policies will not have sub-limits, and some insurers offer options to opt out of the clause. But, in general, a health insurance plan with a sub-limit will have a lower premium than those without sub-limits.

Thus, when you choose a health insurance policy, carefully note the sub-limits. While these may be better for your budget, ensure that they also fit your requirements, as health insurance plans with sub-limits can end up providing more limited coverage in the long run.

There are three major types of sub-limits in health insurance. Let’s take a look at them so that choosing an insurance policy will be simpler for you:

Sub-Limit on Room Rent

When it comes to room rent, your insurer will usually cover the room rent per day, but only up to a certain limit. This amount is usually between 1–2% of the sum insured, or some other fixed amount of money.

So, if your room rent cap is ₹4,000 per day, and you opt for a room that is ₹6,000 per day, you will have to pay the difference of ₹2,000 out of pocket.

Additionally, some insurers will also place limits on the type of room, such as covering only general wards or semi-private rooms. Note that based on the type of room you opt for, medical expenses such as doctor’s consultation charges or oxygen supply fee may vary.

Sub-Limit on Specific Treatment

Sub-limits also often apply to specific treatments and/or diseases, especially those that are very common and pre-planned procedures, such as kidney stones, cataracts, piles, gallstones, hernias, tonsils, sinus, etc. Under the sub-limit clause, your insurer will only bear a certain percentage of the bill for these treatments.

For example, if your sum insured is ₹15 lakhs, but your policy has a sub-limit clause of 50% for the treatment of cancer, you cannot claim more than ₹7.5 lakhs for this treatment.

Sub-Limit on Pre or Post Hospitalization

Some health insurance providers also include sub-limits for pre and post-hospitalization expenses.

If your policy covers pre-hospitalization expenses (ex. for diagnostic tests), and post-hospitalization expenses (ex. Medications, therapies, or tests during recovery), these may also be subject to a sub-limit.

As we have seen above, when there is a sub-limit, it reduces the final claim amount. For things like hospital room rent, treatments of certain diseases, or post-hospitalization charges, you can only make a claim for the amount set out by the sub-limit clause, and beyond that, you need to pay out of your own pocket.

Thus, even though you might have a high sum insured is high, you may not be able to claim for all of your hospitalization or treatment expenses due to these sub-limit clauses.

Remember to go over these sub-limit clauses carefully to avoid any last-minute confusion during the stressful time of hospitalization or while filing a claim. This way you can ensure that you enjoy a hassle-free claims process.

While you can shop around for policies that don’t offer sub-limits, these will often have higher premiums. Since sub-limits are decided by the insurance company, if you choose a policy that has these clauses, you will not be able to change the amounts.

Thus, before you buy a policy, thoroughly understand the sub-limits mentioned in the policy documents and check the other important factors, like inclusions, exclusions, deductibles, and co-payments. If you feel that the coverage offered in the policy falls short of your specific requirements or costs for healthcare, you can increase your sum insured, or even opt for a different insurer.

Understanding sub-limits in health insurance is very important, as it can become a factor in deciding whether or not a policy fits your requirements. While a health insurance plan with a sub-limit will have a lower premium than those without sub-limits, they can end up providing more limited coverage in the long run. So, be sure to look for a policy that fits both your healthcare needs and your budget before purchasing your health insurance.