When buying health insurance, certain factors need to keep in mind to avail the best possible coverage. Among all essential factors that you need to consider, one of them is sub-limit. One of the crucial elements but most underrated in a health insurance policy. The sub-limit needs to be evaluated while buying a health insurance policy. Let's understand this factor with an example.

Nancy and her sister Kia bought a health insurance policy of INR 5 lakhs, each with the same benefits. After six months, Nancy and Kia met with an accident and had to be hospitalized. While Nancy was aware that her health insurance room rent sub-limit is INR 5000 per day; she opted for the same cost room as her allowance. But Kia bought the insurance because her sister insisted, and she was unaware of her room rent allowance. Kia opts for a room that costs INR 7000 per day. At the time of bill settlement after three days of hospitalization, Kia had to pay INR 6000 extra out of her pocket while the insurer paid Nancy’s entire three days hospitalization room rent. Kia was disappointed and asked Nancy what is the sub-limit? Why does it sound complicated? Many policyholders like Kia have bought the health insurance policy because someone suggested it without knowing what is the sub-limit in health insurance and why it is crucial. Let us understand about it in this article below.

What is a Sub-Limit in Health Insurance?

In a health insurance policy, sub-limit is the fixed coverage amount on a particular claim for a specific disease or treatment procedure. Sub-limit can be a specific amount or percentage of the sum assured. The health insurance companies mostly set the sub-limits on hospital room rent, ambulance, or on some pre-planned medical plans: cataract surgery, hernia, knee ligament reconstructions, retina corrector, dental treatment, etc.

Why Sub-Limits are Important in a Health Insurance Plan?

• Cost Management for Insurers: Sub-limits help insurance providers control rising healthcare expenses, keeping overall premiums affordable.
• Room Rent Restrictions: Many policies set a daily cap on room rent, such as 1% of the sum insured, which impacts room eligibility during hospitalisation.
• ICU Charges: These often have separate sub-limits, typically 2% of the sum insured per day.
• Procedure-Specific Caps: Common surgeries like cataracts or maternity have fixed reimbursement limits irrespective of actual costs.
• Transparency in Coverage: Sub-limits make it easier to understand what’s included and what isn't, helping avoid claim surprises.
• Influences Claim Settlement: Exceeding a sub-limit may reduce the reimbursement amount, even within the total sum insured.
• Impacts Plan Selection: Policies without sub-limits generally come at a higher premium but offer more flexibility during claims.

For balanced coverage with access to 18,400+ cashless hospitals, Bajaj Allianz General Insurance Company offers plans with transparent terms and reliable claim support.

इसे भी पढ़ें: भारत में हेल्थ इंश्योरेंस प्लान के तहत डेंटल ट्रीटमेंट के लिए कवरेज

Types Of Sub-Limit in Health Insurance

हेल्थ इंश्योरेंस खरीदने से पहले, पॉलिसीधारक को सबसे पहले उन बीमारियों की लिस्ट देखनी चाहिए जिन्हें सब-लिमिट के साथ कवर किया जाता है और यह चेक करना चाहिए कि उन पर कितनी सब-लिमिट लागू होगी. सब-लिमिट को दो कैटेगरी में विभाजित किया जाता है:

बीमारी विशिष्ट सब-लिमिट

The ailments specific sub-limits refer to standard pre-planned medical procedures such as cataract surgery, kidney stones, hernia, tonsils, piles, and many others. The monetary cap on the list of the ailments can vary from one health insurance company to another. For example, if the health insurance policy has a cap amount of INR 50,000 on cataract surgery, and the surgery cost is INR 70,000, the insurer will only pay INR 40,000. The rest amount of INR 30,000 needs to be borne by the policyholder. Even though the sum insured can be high, there can be a condition for specific ailments where the policyholder cannot claim the entire amount due to the sub-limit clause.

For example, for cancer treatment, there is a sub-limit clause of 50%. Even if the policyholder’s total sum assured is INR 10 lakh; still, the policyholder cannot claim the amount of more than INR 5 lakh for the treatment due to the sub-limit clause mentioned in the health insurance policy the policyholder has chosen.

हॉस्पिटल रूम रेंट पर सब-लिमिट

अधिकांश हेल्थ इंश्योरेंस पॉलिसी प्लान में, हॉस्पिटल रूम रेंट और आईसीयू पर सब-लिमिट कैप क्रमशः सम इंश्योर्ड का 1% और 2% होती है. मरीज़ द्वारा चुने जा रहे रूम के प्रकार के आधार पर अलग-अलग हॉस्पिटल अलग-अलग रूम पैकेज प्रदान करते हैं.

For example, if you have a health insurance policy plan with a sum assured of INR 5 lakhs, you can opt for a hospital room of INR 5000 per day. If you choose the higher hospital room, you need to bear the extra amount of expense. Similarly, the ICU sub-limit will be INR 10,000. Policyholder sum assured: INR 5,00,000 Room rent sub-limit: INR 5000 per day Actual Room Rent: INR 6000 per day No. of hospitalization days: 5 days

Many health insurance policies also have a sub-limit on post-hospitalization expenses such as medicines, tests, doctor visits, etc. The policyholder can claim once he/she is discharged from the hospital.

इसे भी पढ़ें: भारत में हेल्थ इंश्योरेंस में को-पे क्या है

अंतिम विचार

हेल्थ इंश्योरेंस कंपनियां पॉलिसीधारकों के कुल क्लेम को कम करने और पॉलिसीधारकों को भुगतान करने के लिए अपनी देयता को सीमित करने के लिए सब-लिमिट निर्धारित करती हैं. मेडिकल एमरजेंसी के दौरान आसान क्लेम प्रोसीज़र सुनिश्चित करने के लिए हेल्थ इंश्योरेंस प्लान चुनते समय सब-लिमिट की तुलना करना आवश्यक है. बिना सब-लिमिट के आने वाली हेल्थ इंश्योरेंस पॉलिसी की प्रीमियम राशि उच्च होती है.

अक्सर पूछे जाने वाले प्रश्न

हेल्थ इंश्योरेंस पॉलिसी में सब-लिमिट का क्लॉज़ क्यों अनिवार्य है?

हेल्थ इंश्योरेंस पॉलिसी में सब-लिमिट का क्लॉज़ यह सुनिश्चित करता है कि पॉलिसीधारक अपनी पॉलिसी का उचित उपयोग करेगा. इस प्रकार, यह पॉलिसीधारक को रोकता है कि वह अनावश्यक मेडिकल सेवाओं पर सिर्फ इसलिए अधिक खर्च न करे, क्योंकि इंश्योरेंस कंपनी उनका भुगतान करेगी.

अगर पॉलिसीधारक फैमिली फ्लोटर हेल्थ इंश्योरेंस प्लान का विकल्प चुनता है, तो क्या उसमें कोई सब-लिमिट क्लॉज़ होगा?

हां. फैमिली फ्लोटर हेल्थ इंश्योरेंस प्लान में सब-लिमिट होती है. आमतौर पर, इंश्योरर मैटरनिटी के खर्चों पर सब-लिमिट लागू करते हैं.

What is disease sublimit in health insurance?

An insurer puts a sub-limit on treatments for such ailments and procedures. For example, there could be a clause which specifies that an insurer will bear only 80% of the bill or 1% of the sum insured can be used for treatments with sub-limits.

What does a sub-limit mean in an insurance policy?

A sub-limit is a pre-set cap on reimbursements for specific treatments or expenses within your overall health insurance policy.

How is a sub-limit different from a deductible in health insurance?

A sub-limit restricts payout for certain expenses; a deductible is the amount you must pay before the insurer contributes.

What is the difference between overall limits and sub-limits in a policy?

Overall limits cap the total policy benefit, while sub-limits cap specific treatments like room rent or procedures.

Can you provide an example of a sub-limit in health insurance?

Yes. If your policy has a room rent sub-limit of ₹5,000/day, and you opt for a ₹7,000/day room, the excess cost is borne by you.

Which coverage benefits typically come with sub-limits?

Common areas include room rent, ICU charges, cataract surgery, maternity, and post-hospitalisation care.

How can I find out which sub-limits apply to my health insurance plan?

Refer to your policy wording or schedule, or consult with your insurer for a detailed breakdown.

*स्टैंडर्ड नियम व शर्तें लागू। इंश्योरेंस आग्रह की विषय-वस्तु है. लाभों, शामिल न की गई चीज़ों, सीमाओं, नियम और शर्तों के बारे में अधिक जानकारी के लिए, कृपया इंश्योरेंस खरीदने से पहले सेल्स ब्रोशर/पॉलिसी डॉक्यूमेंट को ध्यान से पढ़ें.