When you buy a health insurance policy, you need to keep in mind that there are certain sub-limits that exist. These sub-limit are specified coverage limits up to which you will be able to make a claim. Admission in the ICU is a costly affair, and most plans cover ICU charges up to 1% or 2% of your total sum insured. With a higher sum insured you may be able to get more coverage for the ICU charges. There may also be a daily benefit for ICU to manage ICU charges per day, depending on the kind of health insurance plan you have opted for.
Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024.
The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918
An ICU has many types of equipment required to monitor the vitals of a patient which are highly advanced. Furthermore, an ICU has to be extremely sterile for severely ill patients and thus, requires air conditioners and air filtration systems at all times. Some of the ICU equipment include:
Heart rate monitor
Blood pressure monitor
Ventilator services
Oxygen level monitoring
In addition to the advanced equipment, the ICU charges also include the cost of senior nurses and doctors. The manual labour costs are significantly high as ICU patients require round-the-clock monitoring and regular checkups throughout the day.
When it comes to certain medical conditions or facilities, health insurance plans have a sub-limit in place which outlines the extent of expenses to be covered by the insurer. The sub-limit applicable to room rent in health insurance also covers ICU charges for intensive medical care.
In simple terms, a room rent clause limits the cost of the room covered under the plan to a certain percentage of the total sum insured. So, if you have a health insurance policy with a coverage of ₹1 lakh, and you have a room rent limit of 2%, then the insurance company will only cover up to ₹2,000 a day towards room rent. As we have seen, ICU rooms can be quite expensive when compared to other hospital rooms. This could result in expenses related to your room exceeding the amount that your policy covers.
How this plays out is a little more complex than it may seem. Let's take the above example. If your room rent comes out to be ₹6,000, your health plan has a room rent limit of 2%, which is ₹2,000 for a sum insured of ₹1 lakh. You may assume that all you have to do is pay ₹4,000 per day for your hospital stay, right? Not quite! The reason you do not pay a flat ₹4,000 per day based on the previous example is that insurance companies take into account what is known as ‘proportionate deduction’.
Insurance companies include sub-limits in health insurance policies to reduce the overall medical care expenses. Moreover, these sub-limits are set after considering the average rates charged by various hospitals. Hence, insurance providers are able to secure themselves against fraudulent claims or inflated hospitalisation bills submitted by policyholders.
Although many health plans have sub-limits in place, there are insurance providers offering policies without such a clause. But you must know that insurance plans without a sub-limit clause have a higher premium when compared to policies with a sub-limit. Thus, it is crucial to understand the terms and conditions of your health plan and ensure that the insurance coverage is sufficient. Even though health plans with sub-limits might be more affordable, they may limit your insurance coverage in the long term.
As sub-limit clauses are decided by the insurance company, you must read the terms and conditions mentioned in the plan. If you opt for a health plan with sub-limits, you cannot change it later and thus, you need to ensure that the coverage is sufficient for you. Go through the features, exclusions, co-payment and deductible clauses to understand the insurance policy better. In case you cannot avoid sub-limits in health insurance, make sure the policy satisfies your requirements. Although insurance without such clauses shall come at a higher premium, the coverage might not be sufficient in the long run.
One thing to note while considering ICU charges in a hospital is that the cost of the room is not directly proportional to the quality of treatment you receive. Furthermore, getting an expensive room may also determine how costly your overall treatment will be and thus, how smooth your health insurance claim process will be.
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You shall find health insurance sub-limit clauses applicable on certain medical treatments, conditions, and pre and post hospitalisation expenses.
Based on the type of sub-limit you exceed, the penalty might vary and you might have to bear out-of-pocket expenses. But this may differ from insurer to insurer.
There are numerous exclusions that are not covered under health insurance plans but they may differ depending on your insurer as well. Read more about diseases not covered under health insurance on our platform!
The best you can do is ensure that the hospital is not overcharging you. That aside, treatment in the ICU is essential, and it is best to make sure you do not try to cut costs here.
Generally, insurance providers might permit up to 2% of the total sum insured per day.