Understanding Sub-Limits in Health Insurance Plans


In addition to coverage, there are many other factors to consider while shopping for a health policy in India, such as deductibles, co-payments, and waiting periods. Sub-limits are another vital aspect of health insurance to keep in mind. *


The insurer places a predefined monetary cap on your claim amount, known as a sub-limit. However, it is vital to note that the sub-limit in health insurance will not apply to the total bill amount but to specific conditions. These restrictions include hospital room rent, specific disease treatments, ambulance fees, and more. Sometimes, this sub-limit may be expressed as a percentage of your total coverage. For instance, if your SI is 5 lakh and your rental expenses are regulated at 1%, your insurance will cover up to 5,000 of your rental charges. *


The Significance of Sub-Limits in Health Insurance: Insurance firms implement sub-limits to lower their overall claims. While they are often established at the average rates most hospitals charge, they can also reduce fraud and inflated medical bills by patients. There will be no sub-limits on health insurance contracts, and some insurers provide the option to opt out of the restriction. In general, however, a health insurance plan with a sub-limit will have a lower premium than one without. Consequently, when looking at the sub-limits, ensure that you have thoroughly looked into health insurance comparison. Although these may be more affordable, make sure they meet your needs, as health insurance policies with sub-limits may provide less coverage in the long term. *


What are the Many Types of Sub-limits?

There are three primary sub-limit kinds in health policy in India.

Let’s examine them so you can choose the best mediclaim policy more easily:


Sub-Limit on Room Rent: Your insurer will often cover the daily lodging rent, but only up to a specific cap. This amount is often between 1% and 2% of the insured value or another predetermined sum of money. If your room rent cap is 4,000 per day and you choose a room that costs 6,000 per day, you will be responsible for the 2,000 difference. In addition, some insurers set restrictions on the room type, such as only covering general wards or semi-private rooms. Remember that medical expenses such as doctor’s consultation fees and oxygen supply fees may vary based on the room type you select. *


Sub-limit on Particular Therapy: Sub-limits frequently apply to certain treatments and/or conditions, particularly those very prevalent and pre-planned, such as kidney stones, cataracts, piles, gallstones, hernias, tonsils, sinus, etc. In accordance with the sub-limit clause, your insurance will only cover a set proportion of the cost of these therapies. For instance, if your insurance contains a sub-limit provision of 50% for cancer treatment and your sum covered is 15 lakhs, you cannot claim more than 7.5 lakhs for this treatment. *


Pre- or post-hospitalization Sub-Limits

Some health insurance companies impose sub-limits for pre- and post-hospitalization charges. Suppose your insurance covers pre-hospitalization charges (such as diagnostic tests) and post-hospitalization expenses (such as medications, therapies, or testing during recovery). In that case, they may be subject to a sub-limit as well. *


Are Sub-limits Required?

Although you can browse for insurance without sub-limits, the premiums for these products are typically higher. As insurance companies determine sub-limits, you cannot alter the amounts if you select a policy with these restrictions. So, when considering mediclaim vs health insurance, you should thoroughly comprehend the sub-limits outlined in the policy paperwork and examine the other significant factors, such as inclusions, exclusions, deductibles, and co-payments. If you believe the policy’s coverage falls short of your individual needs or healthcare costs, you can increase your sum insured or choose a different insurer. *



* Standard T&C Apply


‘Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.‘

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