Understand sub-limits in your health insurance before you buy

Health Insurances 154 views

Selecting the most suitable health plan is a tough task as there are many health insurance products and companies are available in the market. There are various features that one should compare and count upon before buying a health insurance plan. While buying the health insurance plan you should not only focus on the maximum limit you can avail in health insurance or the sum assured, premium pay outs. Moreover, you should also focus on different things such as day-care procedure and deductibles, co-payment, sub-limits and waiting period in medical insurance policy, etc.

What is a sub-limit?

Most of the health insurance offers you a sum insured or you can say that you are covered up to sum insured. The insurance company can limit its liabilities in specific cases through sub-limits. For instance: If you have taken a health insurance policy of sum assured Rs. 5 lakhs. It might be it offers you a sub-limit of Rs. 50,000 only for maternity cover. However, the upper limit of your plan is Rs. 5 lakhs, but for maternity cover the plan has a sub limit of Rs. 50,000 only. Apart from the specific limit for different treatments there could be other sub-limits as well. The plans with sub limits are less expensive than those with no limits.

The most important among sub-limits is the room rent (sub-limit). This is one such limit, which if not understood well can create hole in your overall budget.

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What is a room-rent sub limit?

According to this sub-limit, the insurance company covers the room rent per day only up to a certain limit. For instance, if your hospital room rent is Rs. 6000 per day and your policy offers the sub-limit to maximum Rs. 4,000 per day. In that case, you need to pay the difference from your pocket.

How policy holder calculate the sum?

A number of customers are not much concerned about paying the difference amount as you are supposed to pay a marginal amount in the overall cost of hospitalisation. In most of common assumption, if you are paying Rs. 20,000 from your pocket for 10 days hospital stay, you don't mind paying so, because the other charges and bill is paid by the insurer. If you are thinking the same way, get ready to be shocked at the time when you claim the bill.

Different type of charges included by hospitals

Hospital charges are linked into different forms and for different services during your stay in hospital. It sounds strange, but hospitals charge bill on various services and factors. Same procedure, operation and same instruments and same doctor, but the charges vary from room to room and service to service. If you are staying in a sharing room, it might be your doctor's room visit might cost you Rs. 1000 and if you are staying in deluxe room it might be your doctor's visit cost your Rs. 2000 or more. The charges of bandages, snacks and refreshments are not included in your claims. Therefore, the estimated cost that you are expecting go beyond your imagination once you receive the bill.

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How it will affect your bill and insurance claim?

The hospital charges are linked to the type of room, the difference in the bill is not restricted to the difference in the room rent, but the difference is based on other parameters as well. If your health insurance plan is not having any sub-limits in that case the insurance company has no option other than covering everything in claim. But, if your plan has limits and different caps for different categories, in that case you will get the maximum benefits upto your sub-limit. Let's understand this with an example:

Sum insured: Rs. 500,000
Sub limit: Rs. 1 lakh

Hospital charges for 10 days
Hospital services Actual charges Reimbursed charges
Actual room rent Rs. 50,000 Rs. 20,000
Doctor's visit charges Rs. 20,000 Rs. 10,000
Medical test Rs. 35,000 Rs. 20,000
Operation charges Rs. 200,000 Rs. 160,000
Total cost Rs. 30,5000 Rs. 210,000
Cost born by you Rs. 95,000

Therefore, it is important to check the health insurance policy on sub-limits basis as well before you buy it. But, it you are buying a policy, which has no limit or cap for different treatments and expenditures is a good option to buy if you can afford the premium amount of the policy. Don't be always in an assumption that you are having the maximum limit of spending on any treatment to the sum assured. Always try to inquire more about the sum-limit in your health policy while purchasing one.