Let us say Rajeev Ranjan has a health insurance policy that has a sum assured of Rs 5 lakh. If he has surgery where his hospital bill is Rs 5 lakh, does it mean that he will not have to pay anything from his pocket? 
 
Not always. One of the reasons could be the presence of something known as insurance sub-limits. 

What are sub-limits?
Sub-Limits are nothing more than a cap placed on the total amount that is insured for particular coverages, illnesses, claim types, and so on. The payment shall be provided in accordance with the limit that was stated at the time the policy was issued, with the sub-limit at the time of claims serving as the determining factor. 

"The sum Insured in a policy is the maximum limit the policy will pay. Sub Limits in health policies are incorporated to limit the liability on certain procedures, items, etc., within the sum insured," says Shreeraj Deshpande, head of health businesses at SBI General Insurance. 

Sub-limits can be for diseases/procedures, the most common being cataracts, maternity & some other specific ailments listed. "Sub-limits may also apply to claims outside the insurers' provider network. Limits may be capped on the category of the room allowed to be availed by the insured. There may be sub-limits on road ambulance payments, and alternate treatments availed viz. ayurvedic & homeopathic, etc.," says Bhaskar Nerukar, head of the health administration team, Bajaj Allianz General Insurance. 

For example, a policy has a sub-limit for maternity, where for normal delivery, it is at Rs 30,000, and for a caesarian (CS), it is at Rs 50,000. There could be a sub-limit of Rs 2,500 per day on room rent, or there could be one per cent of the sum insured per day for room rent, etc. There could be a sub-limit for cataracts at Rs 75,000, etc. If a policy has an OPD cover with an annual limit of Rs 10,000, however, there could be a sub-limit of Rs 2,500 for dental surgeries. 

• Outlook India
• 29/11/2022