Do you know that your health insurance might not pay the complete amount for certain medical expenses? If you are wondering why, then you must learn more about important policy terms, including ‘Sub-Limits.’ An infamous insurance term – sub-limit in health insurance – is rather an essential element that keeps premium amounts affordable for the customers. Read on to learn how sub-limits work and get answers to more FAQs about its schedule.
1) What is a Sub-limit in Health Insurance and How does it Work?
Sub-limit is a pre-determined capping applied by the insurer on certain medical expenses under your health insurance. It works as a limit on how much claim amount will the insurer pay for a given healthcare expense. Sub-limits are usually calculated in percentage form and applicable to both, cashless and reimbursement claim settlement.
Let’s elaborate on what sub-limit means using an example. Suppose you have purchased a health cover with a 5 Lakh sum insured including a sub-limit on ICU charges for 1% of the insured. That means the insurer will only pay you INR 5,000 for ICU charges and anything above will be borne by you. See the table below for a better understanding:
| Total Sum Insured |
Sub-limit on ICU Charges |
Actual ICU Charges |
ICU Expenses Paid by the Insurer |
ICU Expenses to be borne by you |
| 10,00,000 |
1% of SI |
12,000 |
10,000 |
2,000 |
Wondering how is sub-limit important for you?
With the help of sub-limits, an insurer can reduce its liability and thus, offer health insurance at an affordable premium. It helps you secure yourself and your family with standard health insurance benefits under a budget-friendly premium.
2) What are the Two Types of Sub-limits under Health Insurance?
An insurer can imply sub-limits on multiple benefits and ailments covered under your health insurance. Below are the two major categories of sub-limits you will find on your mediclaim:
a) Sub-limits on Room Choice and ICU Charges: Hospitals have several room categories available at different charges, including private rooms, common wards, and ICU, among others. While you can choose a room as per your needs and preferences, it might involve sub-limits by the insurer.
Generally, insurers apply sub-limits on- Room Rent, Room Category, and ICU Charges. Take a look at the sub-limits applicable under some most-preferred health plans offered by Care Health Insurance:
|
Plan Name
|
Room Rent |
Room Category |
ICU Charges |
| Care Classic |
1% of SI per day for SI less than 5 Lakh |
Single Private A/C Room for SI >= 5 Lakh |
Up to 2% of SI per day for SI< 5 Lakhs
No limit for SI >= 5 Lakhs
|
| Care Advantage |
No Sub-limits |
No Sub-limits
|
No Sub-limits |
| Care |
Up to 1% of SI per day |
Single Private Room
|
Up to 2% of SI per day |
| Care Plus |
1% of SI per day for SI less than 5 Lakh |
Single Private A/C Room for SI >= 5 Lakh |
Up to 2% of SI per day for SI< 5 Lakhs
No limit for SI >= 5 Lakhs
|
| Care Senior |
1% of SI per day |
Single Private A/C Room
(Max. up to 1% of SI per day)
|
2% of SI per day |
Please note: The above-mentioned sub-limits can include certain additional conditions. Please refer to the policy documents for more details.
b) Sublimits on Specified Diseases: Today, insurers are offering dedicated health insurance products for different kinds of people, families, and ailments. This leads to certain limitations as to how many diseases or illnesses can be covered under a given policy. Thus, insurers apply disease-specific sub-limits on treatments that can be claimed under a policy.
Generally, standard health plans include sub-limits on the treatment of ailments like cataracts, knee replacement, hernia, kidney stones, etc. Some insurers may apply partial sub-limits by offering some lump-sum amount for the treatment of such conditions. At Care Health Insurance, we ensure that you can get treatment for a maximum number of ailments with no sub-limits. Here’s a look at the sub-limit schedule under our most-preferred health plans-
|
Plan Name
|
Treatment of Cataract |
Treatment of Knee Replacement |
Treatment of Cancer / Cardiovascular Disorder / Renal Complicatons / Breakage of Bones
|
| Care Classic |
Limited up to Rs 50,000 per eye, Max. up to 75,000 per policy year for SI >=7 Lakhs
|
Up to Rs 1 Lakh per knee |
Up to Rs 2.5 Lakhs
|
| Care Advantage |
No Sub-limits |
No Sub-limits
|
No Sub-limits |
| Care |
Up to Rs 30,000 per eye |
Up to Rs 1 Lakh per knee
|
Up to Rs 2.5 Lakh |
| Care Plus |
No Sub-limit |
No Sub-limit |
No Sub-limits
|
| Care Senior |
Up to Rs 30,000 per eye |
Up to Rs 1 Lakh per knee
|
Up to Rs 2.5 Lakh |
Please note: The above-mentioned sub-limits can include certain additional conditions. Please refer to the policy documents for more details.
3) What are the Coverage Benefits that Include Sub-limits?
Although insueres can apply sub-limits to any benefit within the policy, they are usually restricted to room rents, and treatment of a common list of specified diseases. Also, some insurers can offer insured members to customize sub-limits as per their convenience.
4) How do I know what Sub-limits are Included under My Health Plan?
You can check the policy documents, including the prospectus and terms and conditions to know the complete details of the sub-limits applied under your health policy. Also, you can reach out to the insurer’s csutomer service portal to understand the concept of sub limits in detail.
5) Do All Health Insurance Plans have Sub-limits?
Yes, most of the health plans include some form of sub limits. If you are looking for an all-inclusive plan with no sub-limits, check out ‘Care Advantage– Health Insurance Plan with 1 Crore Cover & No Sub-limits.’ The policy includes an exhaustive list of benefits, features, and sum-insured options to secure your entire family with optimum protection.
To Summarize
Health insurance coverage, its limits and conditions can sound complicated if you do not clarify the basics. Elements like sub-limits, deductibles, exclusions, etc., require careful understanding to avoid confusions and disappointments during claim settlement. Thus, always comb through the policy details to keep yourself informed.
>> Also Read What are Sub-limits and their Importance in Health Insurance
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