What are Sub-Limits in Health Insurance?

When buying health insurance, you need to keep in mind several factors to get the best coverage according to your requirements. One of such crucial factors is the sub-limits that individuals often tend to ignore when purchasing health insurance. Sub-limits in health insurance refer to the limit up to which the insurance company will bear the expenses for a specified medical condition. You will need to pay the balance amount should the cost rise beyond the specified limit. This limit will be defined by the insurance company on the overall sum insured for a set of specific diseases or medical treatments. Some of the examples are doctor’s consultation fees, hospital room rent, ambulance charges, cataract operation, etc. Having a proper understanding of sub-limits in your health insurance can help you choose a suitable plan. We’ll thus discuss the definition of sub-limits and their applicability in different situations. Keep reading to know more!

Let’s Understand Sub-limits with an Example

Suppose you have health insurance that has a sum insured of INR 10 lakh. This health insurance plan has a sub-limit on room rent expenses up to 1% of the sum insured. This means in case of a medical emergency, you will get a room rent coverage up to INR 10,000 per day. You will need to pay the amount exceeding this limit.

What are the Different Types of Sub-limits in Health Insurance?

Now that you know the sub-limits in health insurance, you should know where they are applicable. The limits apply to hospital room rent and a few specific treatments. We are providing information about each of them below. Please check!

Sub-limits on Hospital Room Rent

As you can see from the name, this limit will apply to the room rent expenses during your hospitalization. In case of any medical emergency, the insurance company will only pay up to the specified sum limit as set by it. It means your hospital room rent will be paid but only up to a certain limit.

For example, if the sub-limit on your room rent is fixed at INR 2,000 per day and you are choosing a room with a cost of around INR 5,000 per day. Let’s say you have to stay in a hospital for 3 days. The total room rent for these 3 days will be INR 15,000 but the company will only reimburse INR 6,000 according to the sub-limit in your health insurance plan. You will need to pay the balance amount of INR 9,000 (15,000 – 6,000) by yourself.

Sub-limits on Specific Diseases

Health insurance companies also put a specific limit on specific diseases and a few pre-planned medical procedures. When you choose a health insurance plan, you should always check those specified diseases or conditions that come under the sub-limits on your particular health insurance plan and the amount up to which you will get the cover. Some of these specific diseases and treatments are kidney stones, cataracts, hernias, tonsils, knee ligament reconstruction, plastic surgery, sinus, cancer, etc. You need to understand that having a high sum insured amount does not mean you will get comprehensive coverage for all conditions. Also, the sub-limit may vary from one policy to another depending on the disease or specific condition.

Let’s say you have a health insurance policy with a sub-limit of 30% for hernia treatment. So, even if your overall sum insured is INR 5 lakh, the company will not provide coverage more than INR 1,50,000 for your treatment.

Other than these two types, health insurance companies put a sub-limit on room rent, doctor’s consultation charges, ICU charges, Blood, oxygen, ambulance charges, diagnostic tests, etc. So, you need to keep them in mind too when choosing a health insurance plan for yourself.

Sub-limits in Different Health Insurance Policies

We are showing some of the top health insurance policies and their sub-limits on different medical conditions in the below table. Do check!