What are sub-limits in a health insurance policy?

When choosing a health insurance policy for a family, understanding the finer details, such as sub-limits, is crucial. Many policyholders overlook this aspect, only to face financial surprises during claims. Sub-limits in health insurance can impact how much you are reimbursed for specific medical expenses. In this blog, we will explore what sub-limits are, their importance, types, and how they affect a health insurance plan.

What is a sub-limit?

Sub-limit is a monetary cap that your insurer places on your health insurance claim. It limits the reimbursement amount for certain treatments, room rent, or procedures, even if the total sum insured is higher.

Let us assume-  due to medical complications, my wife's medical bill went up to Rs. 1 lakh. Our health policy had a sub-limit of Rs. 40,000 for the treatment of kidney stones. Hence, I will have to shell out the balance of Rs. 60,000 from my pocket.

What is the sub-limit in health insurance?

In a health insurance for family, a sub-limit determines how much the insurer will pay for particular medical expenses. It applies to hospital room rent, doctor's consultation charges, ambulance charges and a few common medical procedures as well.

Importance of sub-limit in a health insurance plan

Understanding sub-limits in a health insurance plan helps in:

1. Managing out-of-pocket expenses: Policies with lower sub-limits may require you to pay more from your own pocket.
2. Choosing the right coverage: Helps in selecting a health insurance policy with flexible or no sub-limits for better financial security.
3. Optimising premium costs: Policies with sub-limits tend to have lower premiums, making them cost-effective.
4. Avoiding claim disputes: Knowing sub-limits beforehand ensures smooth claim settlement without unexpected deductions.

Types of sub-limits in health insurance

Sub-limits can vary based on the insurer and the policy. The common types include:

1. Room Rent Capping

• Limits the coverage on hospital room charges per day.
• If you exceed the limit, the extra cost is borne by you.
• Example: A sub-limit of ₹4,000 per day on room rent means you pay extra if you choose a more expensive room.

2. Treatment-Based Sub-Limit

• A cap on specific medical procedures like cataract surgery, hernia surgery, or joint replacement.
• Example: A ₹40,000 sub-limit for cataract surgery means you will bear the additional cost if the surgery expenses exceed this amount.

3. Post-Hospitalisation & Pre-Hospitalisation Expense Sub-Limit

• Limits reimbursement for diagnostic tests, doctor consultations, and follow-ups before and after hospitalisation.
• Example: If your health insurance plan covers pre-hospitalisation expenses up to ₹10,000 but your actual expenses are ₹15,000, you pay the ₹5,000 difference.

4. Specific Disease or Illness Sub-Limit

• Some policies have sub-limits on high-cost treatments like kidney dialysis, chemotherapy, or heart surgeries.
• Example: A health insurance policy for a family may cover heart surgery up to ₹2 lakhs, even if the total sum insured is ₹10 lakhs.

5. Ambulance Charges Sub-Limit

• Caps on ambulance expenses for hospitalisation.
• Example: A sub-limit of ₹2,000 on ambulance costs means you’ll pay extra if the actual charge is ₹3,000.

Conclusion

Now that you know about sub-limits on insurance policies, you are ready to take a look at your own health insurance. Firstly, enquire about the sub-limit clause in your existing health policy. In case you feel that your coverage isn't adequate, as a next step, opt for upgrading the Sum Insured. When choosing a health insurance policy for a family, consider whether you prefer a lower premium with sub-limits or a comprehensive plan without restrictions. Remember to read the policy fine print and look for co-payment and other restrictive options. Lastly, go through the list of exclusions before selecting a policy that best suits your needs and finances.

Disclaimer: The information provided in this blog is for educational and informational purposes only. It is not intended as a substitute for professional advice, diagnosis or treatment. Please consult a certified medical and/or nutrition professional for any questions. Relying on any information provided in this blog is solely at your own risk, and ICICI Lombard is not responsible for any effects or consequences resulting from the use of the information shared.