Generally it is not easy to understand the documents of health insurance policy . It is full of technical terms. Buying any health insurance policy without understanding it can be an expensive deal for you. Each insurance policy comes with its own individual terms and conditions. Its terms and conditions may be different from the insurance policy purchased earlier. It also depends on the sum insured, premium and health condition of the insured. In such a situation, ignoring the documents of the insurance policy can be very harmful for you. Sub-limits are one of the important things to evaluate for health insurance.
Know what is sub-limit clause
The sub-limit is the most important in health insurance. Irrespective of the total sum assured under the health insurance policy, the treatment or condition cannot exceed the prescribed sub-limit. According to Amit Chhabra, Head of Policy Bazaar, the sub-limit can be expressed as a fixed amount or as a percentage of the total sum assured. Knowing the sub-limits is very important while evaluating a health insurance policy. Most health insurers include two types of important sub-limits in their policies. Also, some insurance companies make sub-limits optional based on the budget of the insured.
Room Rent Sub-limits
Most of the policies have fixed upper limit for the hospital room rent charges on per day basis. On some occasions the type of room has also been limited. For example consider that your insurance policy covers 1% of the sum insured as room rent. Now, for whatever reason, if you want to stay in a private hospital room, you will have to pay more than the prescribed amount even though you have insurance. Apart from this, the ICU rent may have a different sub-limit altogether.
In addition, the type of hospital room has a direct impact on the other services offered to the patient. This means that the charges for surgical procedures, consultations or any other medical treatment will be costlier for a private room than for a shared room. So, before selecting a hospital room, have a look at the upper sub-limit.
Sub-limit on inpatient treatment
Health insurers often add sub-limits to the specific treatments covered under the policy. It is very important to understand that the sub limit does not depend on the total sum insured. Your total amount may be higher, but the sub-limit can be set to any limit for a particular treatment or surgery. This may prevent you from claiming the total hospital expenses incurred for the treatment.
According to Chhabra, your sum insured can be Rs 5 lakh, while the sub-limit for eye surgery can be only 30% of the total amount. Hence, you will be able to claim only up to Rs 1.5 lakh for the treatment. “However, it is important to note that an insurance policy without a sub-limit always results in higher premiums for the policyholders. Before selecting a hospital for medical treatment, policyholders should ensure that the room rent and fees for medical procedures are within the reimbursement limit of the hospital.
Chhabra explains that to avoid any last-minute confusion and to determine the correct expectation from your claim settlement, you should consider discussing the upper bonds with your insurance provider before choosing a room.