Let's know if proportionate deduction resolves all your confusion surrounding sub-limits in health insurance

Let's know if proportionate deduction resolves all your confusion surrounding sub-limits in health insurance  22nd February 2023

Health insurance consists of myriad terms and conditions that policyholders should read in detail at the time of health insurance policy renewal or purchasing. However, most of us usually do not pay heed to them and suffer at the time of settlement of the claim. An important clause involves sub-limits in a health insurance policy and the subsequent proportionate deduction.

Sub-limits in health insurance policies usually include capping or limiting the room rent during your hospitalisation. There are a variety of rooms available in any hospital, ranging from general wards to semi-private rooms and deluxe rooms. There is also a proportionate deduction clause associated with the sub-limit. Let us understand these terms in detail.

Sub-limits explained.

Sub-limits are limits or maximum percentage of the total sum insured that an insurance company will bear for the hospital expenses under various categories. Insurance companies usually use the maximum permissible room rent in the hospital as a benchmark for deciding the sub-limits.

For example, if your health insurance policy is Rs.5 lakhs and the permissible sub-limit for room rent is 1%, the insurance company will only bear 1% of Rs.5 lakhs or Rs.5000 per day for the rent of your room in the hospital. Any amount over it will have to be borne by you.

In this case, if your room rent is Rs.7000 per day, the excess amount of Rs.2000 over the sub-limit cap of Rs.5000 per day will have to be borne by you. Generally, the sub-limit on room rent ranges between 1%-2% of the total insured amount.

Proportionate deductible clause.

Insurance companies usually insert a proportionate deductible clause in health insurance policies. The companies calculate the excess room rent over the sub-limit allowed in percentage terms. They then deduct a proportional amount from all associated treatment costs, including surgery fees, tests, doctor consultation and visiting charges, ICU charges, etc. The insured has to bear them from his pocket.

Insurance companies use the following formula to calculate the proportionate deduction.

Excess room rent over the room rent limit/ Room rent limit as per the policy x 100
For example, suppose the room rent limit per the policy is Rs.5000 per day, and the actual room rent is Rs.7000 per day. Hence, proportionate deduction to be applied:
2000/5000 x 100 = 40%
In this case, if the doctor consultation fee is Rs.2000, the insurance company will deduct 40% of this amount, i.e., Rs.800, and will cover only Rs.1200. The remaining Rs.800 will have to be borne out of your pocket.

How to deal with the proportionate deductible clause?

You should always check whether the proportionate deductible clause applies to your health insurance policy when purchasing it. If applicable, you should adhere to the sub-limit cap and choose a room accordingly in the hospital, especially if your hospitalisation period exceeds 3-4 days. This will ensure that the insurance company cannot apply the proportionate deductible clause and will cover all expenses during the hospitalisation period.

If your policy includes a sub-limit capping, consider changing your insurer at the time of health insurance policy renewal to one without such a clause. We can also port our policy to some other company for this purpose.

A health insurance policy is fundamental in the present world because of our food habits and lifestyle. However, only some people know the concept of sub-limit capping and proportionate deductible clauses. This can burn a big hole in your pocket in a medical emergency.

Do not worry if your health insurance policy comes with these riders. Shift to another policy or company at the time of health insurance policy renewal. This will protect you while ensuring that the insurance company will bear all the hospital expenditures in case of hospitalisation.

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Disclaimer: The information provided above is for illustrative purposes only. To get more details, please refer to policy wordings and prospectus before purchasing a policy.