Sub Limits in Health Insurance: Meaning & Types Explained

When you buy a Health Insurance policy , you aim to protect yourself from potential financial losses in the event of an ailment or a medical emergency. You may select a Health Insurance policy with a large cover and many perks, but extensive coverage alone is insufficient. You must carefully scrutinise the terms and conditions and be aware of the inclusions and exclusions. Your policy is a contract that is heavily laden with components and technicalities. One such component is a sub-limit.

Sub-limits in your Health Insurance keep a check on your expenses to avoid inflated medical bills. For instance, if you are well covered, you would like to take the policy’s maximum benefit by opting for better facilities. However, your insurance policy may have a cap on the claim amount for some of the facilities provided in your plan, like room rent, ambulance charges, doctors’ fees, and the cost of surgery, among others.Sub-limits reduce the liability for your insurance company. It also means policies with more sub-limits have lower premiums since you must spend from your pocket for any expense that exceeds the sub-limit.It is essential to be clear about the meaning of sub-limits in Health Insurance and the types of sub-limits you may encounter in your plan.Sub-limits are a percentage of the sum assured or a specific amount specified by the insurance company. Also read: What Are the Benefits of Health Insurance?

There can be various sub-limits in Health Insurance that restrict the coverage for specific expenses. Here are some typical Health Insurance limits explained:

Room rent:

This type of sub-limit in Health Insurance sets a cap on the amount your insurance company will reimburse for your hospital room rent per day. If the room rent exceeds the sub-limit, you bear the additional expenses. For instance, during hospitalisation, if you select a room on a twin-sharing basis, that costs ₹ 3,500 a day. If your policy has a sub-limit of ₹ 2,000 a day, you are required to pay the balance ₹ 1,500 out of your pocket.The policy might limit the room type you can use. For instance, some insurance companies cover the charges for general or semi-private rooms when you are admitted. You must pay the additional cost from your pocket if you need a private room.

Surgery:

There may be a cap on the coverage for surgical procedures, meaning that regardless of the actual cost of your surgery, your insurance company will only reimburse expenses up to the specified sub-limit.

Maternity:

This sub-limit applies to maternity-related expenses, including pre- and postnatal care, delivery charges, and hospital stay. The coverage is limited to the predefined sub-limit, and any costs exceeding that will be from your pocket.

OPD:

Some Health Insurance policies have a sub-limit for outpatient department (OPD) expenses. This clause restricts the coverage for consultations, diagnostic tests, and medication incurred without hospitalisation.

Specific disease:

Even if you purchase a policy with a higher sum assured, you may not be able to claim the entire amount due to the sub-limit clause on specific medical procedures. For instance, if your Health Insurance plan has a sub-limit clause of 50% on cancer treatment, even if your sum assured is ₹ 5 Lakhs, the insurer will not pay more than ₹ 2.5 Lakhs.Review the list of diseases/illnesses eligible for full coverage and which treatments come under the sub-limit clause. Also read: What Does Your Health Insurance Policy Cover?

Sub-limits can impact the overall claim settlement process by limiting the reimbursement amount for specific treatments, such as maternity care or cancer, and expenses, such as hospital room rent or ambulance charges. If your expenses exceed these sub-limits, you may be required to bear the additional costs yourself.Remember, these sub-limits can affect your claims even if your sum assured is reasonably good. Also read: Super Top-Up Health Insurance – What’s That?

• Sub-limit in Health Insurance means a monetary cap that your insurer may impose on specific treatment expenses.
• Sub-limits may be expressed as a percentage of the sum assured or a specific amount specified by the insurance company.
• There may be different sub-limits for expenses like room rent and certain surgeries like cataracts, maternity or OPD. Thus, if your policy provides a sub-limit on a cataract operation, you must bear the expenses if they exceed the capped amount.
• If there are many sub-limits in your Health Insurance policy, your premiums will likely be lower.
• Sub-limits help you and your insurance company manage risks and control costs by placing pre-determined caps on specific claims.