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What are sub-limits on health insurance? All you need to know!

What are sub-limits on health insurance_ All you need to know!

In recent years, health insurance has become a necessity due to the rise in lifestyle ailments and constantly rising health care costs. When shopping for proper health insurance, there are many factors to consider to get the best coverage possible. It is recommended that you are familiar with and understand insurance jargon, such as floor levels, critical illness, and pre-existing medical insurance-related illnesses. Of all these essential features, the lower limit is the most underrated feature, despite being one of the most important parts of any health insurance plan.

What is a sub-limit?

A lower limit clause in health insurance is an upper limit that the insurer imposes on the policyholder for the expenses of a specific medical procedure. This is usually a limit set by the insurer on the total amount of the claim for certain diseases or certain medical treatments. Insurers primarily set minimum levels on medical consultation fees, hospital room rentals, ambulance costs, and certain pre-planned medical procedures such as plastic surgery, cataract surgery, knee ligament reconstruction, and a few others.

However, it should be noted that the lower limit will generally vary from claim to claim. In some cases, the lower limit can be a defined percentage of the total sum insured, while in other cases it can be up to an amount set by the insurer. As a general rule, the costs of intensive care and the upper limit for the rent of the sick room are 2% and 1% of the total sum insured, respectively. Let’s understand this better with a small example.

If you have Rs 10 lakh sum insured health insurance, your room rental limit at a 1% rate is Rs 10,000, which means you can choose a hospital room with a room rental of up to Rs 10,000 / day. In connection with certain medical acts, such as cataract ablation surgery, the insurer only pays up to Rs 40,000 for the treatment when the insurer has a limit of Rs 40,000 for cataract treatment. regardless of the sum insured or the cost of the operation.

However, many health insurance companies offer you the option of turning off the lower limits by giving you the option to pay an additional premium. Depending on your budget, you can choose one of two options.

Different types of lower limits

In most cases, a sub-limit is divided into two different categories.

# Disease-specific lower limit

The disease-specific lower limit applies to some common medical conditions and pre-planned medical procedures, including ablation of cataracts, kidney stones, sinus, tonsils, hernias, and reconstruction of ligaments, knees, piles, and more. In most cases, hospitals even include lower limits on medical consultation fees, ambulance fees, oxygen supply fees, anesthesiologist fees, and diagnostic tests (X-rays), among other things. The list of conditions and the monetary limit for each treatment varies from one insurer to another.

# Lower limit for renting hospital rooms

Most health insurances have a lower limit clause on the amount they reimburse for the room rent you pay while you are in the hospital. For example, under a policy of Rs 10 lakh with a lower limit of 1% for renting the room, the insurer approves a sick room with a maximum rent of Rs 10,000 per day. For any room rental amount that exceeds the lower limit established in the policy, the insurer only has to pay the approved limit, and the client must pay the rest of the costs.


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