The reason anyone opts for a healthcare policy is that they wouldn’t have to pay the medical expenses out of their pockets. The general perception is that healthcare claims are supposed to be reimbursed for the entire hospitalization period and clinical visits pertaining to the ailment after discharge. And yet one keeps hearing that they didn’t get full reimbursement of their claim.  There are certain reasons that are mentioned in your policy document. The insured tends to fall into the trap of not reading and understanding the policy which may lead to partial reimbursements. In simpler terms, Know Your Policy is an important step and should not be avoided for smooth claim processes.

Let’s have a look at the reasons this may happen:

Sub Limits:

There’s a clause in your health Insurance policy that defines the sub-limits of your policy. The sub-limits mention the maximum amount that will be paid under each medical head (bifurcation) as per your policy. The sub-heads here include the per day room rent, per day doctor visitation charges, etc.

Here, it is to be understood that even though you may be well within the ‘sum insured’ range of your policy, your claim may still not be reimbursed entirely due to the expenses incurred that exceed the sub-limit clause.

The Sub-limit clause applies majorly to room rents because almost all of the hospitals define expenses based on the room rent. And almost all of the healthcare policies the sub-limit of room rent is capped at 1% of the maximum coverage offered by your policy.

To understand this better let’s take an example. So, If your maximum policy coverage is up to Rs 3 lakh then based on the 1% sub-limit on room rent your maximum limit for room rent per day is Rs. 3000. In case if you have opted for a room with a rent of Rs 4000 per day. When you file for reimbursement your insurer will only allow you the maximum sub-limit benefit (which in this case is Rs.3000 per day). You will have to bear the additional Rs. 1000 per day charges.

Proportional deductions:

Since all the other expense-heads are based on the room rent charges (like doctor visitation charges for a Rs 3000 room would be lesser than a room costing Rs. 4000) other expenses will also get deducted proportionally. These are known as proportional deductions.

The proportional deductions will cumulatively add up the “from your pocket” expenses resulting in a considerable amount by the time the patient is discharged.

Items not falling under ‘medical expenses’:

During the entire hospitalization, there are times when items that do not fall under the medical-expense category are incurred. For example talcum powder, hand gloves, bedsheet charges, etc. As an insured client, you may see these as part of the claim, but they are not considered as medical expenses and therefore will not be paid by the insurer even if you have a cashless policy.

How to avoid sub-limits:

There’s no real turnaround in the sub-limits clause. The best way is to read your policy thoroughly keeping in mind all the criteria so as to avoid paying out-of-your pocket expenses.

Of course, you can opt for a healthcare policy that does not have any sub-limits (yes, there are a few healthcare policies that do not have any sub-limits!). The premium of these healthcare policies is generally on the higher side. But that’s the price you have to pay to avoid any unpleasant surprises.

Another point to keep in mind while opting for a healthcare policy is the city you are living in. And the general hospitalization charges in your city. The idea being hospitals in cities like Mumbai or Delhi will have more charges than a similar room based in tier II city.

While this is all good, people usually do not read their policies before or after buying them. This may be due to lack of inclination or time or just the reason that such documents are tedious to read. And even if they do it is difficult to comprehend all the terms and criteria mentioned in the policy for a person who is new to buying healthcare policies.  It is easier to seek the help of professionals like BimaGarage who can break down the intricacies for you, inform you about the sub-limits of your policy during hospitalization and file a claim on your behalf.


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