What is a sub-limit in health insurance?

A sub-limit is a cap on what the insurer pays for one expense or treatment — room rent, a named surgery or a modern treatment, for example — even when your overall sum insured is not used up. It must be written into your policy with a reference to the clause that applies it. If a sub-limit was applied to your claim, check that it exists in your policy, that your treatment falls within it, and whether a proportionate deduction was added.

One insurer's wording defines a sub-limit as a cost-sharing requirement under which the insurer is not liable to pay any amount beyond a pre-defined limit. IRDAI's guidance on the Customer Information Sheet describes sub-limits the same way: a pre-defined limit above which the insurance company will not pay.^{[1, 2]}

Common kinds of sub-limit

• Room rent and ICU: A daily cap, which may be written as a percentage of the sum insured. In one insurer's product it is 2% of the sum insured a day for a room and 5% for the ICU, each with a rupee ceiling.^[3]
• Named procedures: A cap per procedure — in the same product, cataract treatment is limited to 25% of the sum insured or a fixed amount per eye, whichever is lower.^[3]
• Modern treatments: IRDAI has asked insurers to endeavour to cover technological advancements such as robotic surgery, oral chemotherapy and immunotherapy, but a policy may still cap them: the same product covers its listed modern treatments up to 50% of the sum insured.^{[2, 3]}
• Other named items: IRDAI's CIS format has a row listing the limits a policy pays up to for particular diseases and procedures. Read that row in your own CIS.^[4]

When a room-rent limit reduces more than the room bill

A policy can add a proportionate deduction: if you take a room costlier than your limit, other hospital expenses are also paid only in the same proportion. In one insurer's wording, medicines are excluded from that reduction. Whether a proportionate deduction applies is a product term, and a health policy must state it together with its sub-limits and package rates. Room rent limits and proportionate deduction works through an example.^{[1, 4]}

Checking a sub-limit on your claim

1. 1

   Find it in the policy

   Every sub-limit must be stated with a cross-reference to the policy section concerned. If the settlement letter names a cap you cannot find, ask the insurer for the clause.^[4]

2. 2

   Check the treatment matches

   Make sure the sub-limit names your procedure: compare the procedure in the discharge summary with the exact words of the sub-limit.

3. 3

   Check the base

   If the cap is a percentage of the sum insured, check which sum insured the insurer used against the wording.

4. 4

   Ask for reasons

   A partial disallowance of a health claim must come with full details referring to the specific policy terms relied on.^[2]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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