Health insurance: keep an eye on your policy’s sub-limits

While opting for a policy with sub-limits will reduce the premium payable, it will lead to a decrease in the payment of claims and increase the personal expenses of the policyholder.

When people buy health insurance policies to provide financial protection in the event of a medical emergency due to Covid-19, they should consider the various sub-limits mentioned in the policy as they may reduce coverage. While opting for a policy with sub-limits will reduce the premium payable, it will lead to a decrease in the payment of claims and increase the personal expenses of the policyholder.

Health insurance companies impose a sub-limit on policies that is usually a percentage of the sum insured or a fixed amount. The sub-limits are mentioned in the terms and conditions of the policy document. In policies with sub-limits, the company will not pay the full amount claimed and part of the medical costs will have to be paid by the policyholder.

There are different types of sub-limits such as room charges, treatment of certain illnesses, post-hospitalization, etc., and apply to both cashless claims and reimbursement claims. It is preferable to be admitted for treatment in a network hospital listed by the insurance company because the tariff structure is mutually fixed by the hospitals and the insurance companies.

Sub-limit on room rent
This is the most common form of sub-limit in an insurance policy. Usually, insurers set a cap of 1% and 2% of the sum insured for room rent and intensive care costs, respectively. If the rent for the room chosen by the insured exceeds the rent covered by the policy, then the policyholder will have to pay the rent for the additional room out of his own pocket. As various hospital expenses are related to the type of room that one chooses and according to the ceiling on the rent of the room, there will be a cap on related services such as doctor’s consultation fees, hospital fees. anesthesia, diagnostic tests, etc. the insured must opt ​​for a room fully covered by the insurance policy, even with sub-limits.

Processing sub-limit
Most insurers have sub-limits for planned medical procedures such as cataract removal, reconstruction of knee ligaments, removal of kidney stones, tonsils, sinuses, which is a fixed amount based on on geographic locations. The list of conditions and the limit on treatment costs vary from one insurer to another. The care sub-limit is not linked to the sum insured, which means that even if an insured has a high sum insured, he will not be able to claim the full cost of care due to the sub-clause. police limit. Insureds must be aware of the sub-limits before going for a pre-planned medical act and inform the company or the third-party administrator before being admitted for the pre-planned medical acts. However, there are no sub-limits for emergency treatment like Covid-19 or coronary artery bypass grafting.

Sub-limit in post-hospitalization
In many cases, insureds after treatment may have to stay at home for a period of time under medical supervision. Many insurers take care of post-hospitalization costs with sub-limits where the insured will have to pay part of the costs out of pocket according to the terms and conditions of the policy.

Health insurance policies without sub-limits will have a higher premium compared to a policy with sub-limits in various categories. If a policyholder has coverage with a sub-limit, then he or his family members should ensure that the medical expenses do not exceed the limit.

So, before purchasing a new health insurance policy or renewing your existing one, make sure you opt for coverage that has no sub-limits or else you will end up with limited coverage, especially at some point. where the Covid-19 pandemic is raging across the country.

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