Most people think that they will get full reimbursement of their medical bills under health insurance policy. Not really. There is a possibility that you will only be partially reimbursed by your insurer, thanks to sub-limits.
What are sub-limits?
Sub-limit is a monetary cap on certain components of your health insurance policy. They are usually expressed as a fixed value for a particular disease or treatment but can also be expressed as a percentage of the total sum insured. There are two kinds of sub-limits.One is on hospital room rent and the other on specific treatments. Room rent cap is usually 1 per cent of the sum insured or a fixed value of rent per day. The limit of capping may be different for normal hospitalisation and ICU.
Hospital charges such as doctor visit, surgery, nursing charges, operation theatre charges , and other medical expenses are all linked to the type of room you choose. For instance, doctor’s visit may cost ₹1,000 in a twin-sharing room but ₹2,000 in single room. Say, you choose a room with tariff of ₹5,000 per day. Your total rent for four days will be ₹20,000. But your room rent cap in your policy, say, of ₹2 lakh is ₹2,000 per day. So, the balance room rent of ₹12,000 (₹3,000 x 4 days) will have to be paid by you.
Not just the balance of room rent. Say, all the other expenses such as surgery, medical tests for a ₹5,000 room is ₹2 lakh. This is within your covered amount of ₹2 lakh under the policy. But if the same expenses cost ₹1.50 lakh in a ₹2,000 room, you will have to shell out the additional ₹50,000.
Sub-limits on specific treatments
There is a sub-limit on specific treatments that are mentioned in the policy details.
For instance, if there is a sub-limit clause of 50 per cent of sum assured for cardiac ailment, then even if your sum assured is ₹5 lakh, you cannot claim more than ₹2.5 lakh. Say your medical expense for treating kidney stones comes to ₹1 lakh. But your health policy had a sub-limit of ₹40,000 for treatment of kidney stones. This means that the balance of ₹60,000 has to be paid by you. However, the list of ailments under sub-limits and restrictions in treatment costs vary between insurance companies.
Points to note
Choose a health insurance policy without sub-limits, or after understanding in detail the applicable sub-limits. Go through the list of exclusions before selecting a policy that best suits your needs and finances.
The writer is Chief Underwriting Officer, Bharti AXA General Insurance