You health insurance policy might have a sum assured (SA) of Rs 2 lakhs. However , at the time of a claim you might end up getting much less ? That is because of your sublimits.
What are the sublimits ? Your policy specifies that there are certain subdivisions within the total sum assured and your claim is decided after subdividing and then fitting them into the sublimits. What are the common sublimits which you need to be aware ?
Room Rent.
Many policies specify that your room rent limit is 1% of the sum assured. For a Rs 2 lakhs policy you will then be allowed room rents of up to Rs 2000 per day.Most policies specify a ICCU charge which is higher eg Rs 2 % of S.A. You will be allowed ICCU charges of upto Rs 4000 for such a policy.
Surgeons fees, medicines & consumables
That might be specified under sublimits too. If it is 40 % , then for Rs 2 lakhs S.A. you will be allowed to claim up to Rs 80000 under this head. Some policies club surgeons fees, medicine and consumables together.
In that case an expensive consumable eg a cardiac stent will squeeze out the remaining amount for surgeons fees and medicine.
Limit for specific surgeries
Your policy might have a limit for a specific surgery eg Rs 50000 for cataract. In that case even if your total S.A. is Rs 2 lakhs, you will be allowed to claim only upto Rs 50000 for a cataract surgery.
Any one disease
Some policies would allow only 80 % for any one disease during the policy period. In that case if you are admitted for gall bladder surgery then for a Rs 2 lakhs S.A. Policy you will be allowed Rs 16000 for the total surgery. However, the other sublimits for room rent , surgeons fees and medicine would still apply.
Proportionate Reduction
The charges for medicine, surgeon fees and consumables are reduced proportionate to the room rent sublimit excess. This is a very controversial sublimit which has been disallowed by Courts in many cases of consumer dispute over insurance claim. But one should be aware of it and one Insurance company even charges an extra premium to waive this clause. Here is an example For a policy of Rs 2 lakhs SA with 1% sublimit, the insured takes a room of Rs 3000 then he is exceeding his sublimit by Rs 1000 i.e. 50 %. The Insurance company in certain cases deduct 50 % from surgeons fees . Medicine is usually left out of proportionate reduction.
A careful look at your policy documents will keep you prepared for what to expect from the sublimits if there is a claim.
Please take a look at “ Understanding Your Policy”
You can view the various health insurance policies of this Insurance Company