Imagine this – one day, you feel a throbbing pain in your chest and have to be rushed to the hospital. It turns out that you have a cardiac issue, and it has to be treated immediately.
Once the procedure is done, you get a hospital bill of ₹3 lakhs. However, you have a health insurance cover of ₹ 10 lakhs, and your hospitalisation amounted only to ₹3 lakhs. So, you are relieved, believing your insurer will cover the entire bill.
HOWEVER, during discharge, you find out that only ₹1.5 lakh has been paid by your insurer, and you have to pay the remaining amount. It turns out that your health insurance policy had a disease-wise sub-limit for cardiac-related ailments of only ₹1.5 lakhs.
Reluctantly, you pay the bill and go back home wondering, “What is a disease-wise sub-limit?!”
What are Disease-wise Sub-limits in Health Insurance Plans?
When it comes to health insurance, understanding the fine print can significantly affect how well you are covered. One such important clause is disease-wise sub-limits.
Disease-wise capping or sub-limit in health insurance is a percentage of the sum insured or a fixed amount set aside for treating a particular ailment. Beyond this upper limit, the policyholder will have to pay any additional costs billed.
Since Disease-wise Sub-limits cap the amount your insurer will pay for specific treatments, they can significantly affect your out-of-pocket costs.
But why should you purchase a health insurance policy with a disease-wise sub-limit? More importantly, why do insurance companies include these sub-limits in their plans?
Heads Up: It takes an average person up to 5 hours to read & analyze a policy, and 10 hours or more to compare different plans and make a decision.
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Why are Disease-wise Sub-limits Imposed by Health Insurance Companies?
A disease-wise sub-limit may seem like a restriction to you as the policyholder, but there are a few reasons why insurers impose them. Let’s take a look at some of them now.
- To reduce your insurance premiums – Health insurance policies with sub-limits often have lower premiums. This can make health insurance more affordable for you as the policyholder and enable more people to obtain coverage.
- To reduce insurance frauds – Most insurers have been in the industry for quite some time and have a fair idea of the normal costs associated with various treatments. More often than not, sub-limits are based on these reasonable and customary charges, helping to prevent fraudulent claims and overcharging by hospitals and other healthcare providers.
- To safeguard insurers from inflated claims – By setting a cap on the amount insurers will pay for specific treatments, they protect themselves from unusually high claims. This ensures they can maintain a sustainable business model and continue offering coverage to all policyholders.
While an insurer has several reasons to impose disease-wise sublimits, as a policyholder, there is no reason to pay out of pocket when you have a good health insurance policy. However, there are some cases where it becomes inevitable. Let’s take a look at some of them now.
Should you Purchase a Health Insurance Policy with Disease-wise Sub-limits?
You should never get a policy with a disease-wise sublimit. However, there are cases where a sublimit is unavoidable. They are as follows:
- If you have pre-existing diseases – If you have a pre-existing disease, it is often challenging to purchase health insurance without sub-limits. Insurers impose these sub-limits to mitigate the risk associated with the high cost of treatments. While this may seem restrictive, it allows people with pre-existing diseases to obtain some level of coverage that would otherwise not be possible.
- If you are a senior citizen – Senior citizens are more likely to encounter health issues more frequently and, consequently, higher medical expenses. Insurance companies may impose disease-wise sub-limits to manage the risk of covering older individuals. Despite the restrictions, having a policy with sub-limits is often better than having no coverage at all, as it can still provide financial support in case of hospitalisation.
While it is advisable to avoid policies with disease-wise sub-limits, having some level of coverage in these situations will be more beneficial than not having any coverage. Nonetheless, exploring options that do not impose these restrictions is always more helpful. Here are a few of the top policies in India in 2024 that do not impose any disease-wise sub-limits.
What are the Best Health Insurance Policies without Disease-wise Sub-limits in 2024?
Rest assured, there are health insurance policies that don't impose disease-wise sub-limits and provide comprehensive coverage for your healthcare needs. Here are some of the top policies available in 2024:
- HDFC ERGO Optima Secure: Optima Secure by HDFC ERGO offers extensive coverage with no disease-wise sub-limits. It also has no room rent restrictions and co-payments, ensuring you receive the best possible coverage with minimal restrictions. Adding on to the benefits, this policy also covers consumables by default.
Drawbacks: However, Optima Secure is slightly more expensive than similar policies from other insurers, and this policy also does not cover maternity and international treatments.
2. Care Supreme: If you feel that the only drawback of Optima Secure is how much the premium costs, Care Supreme might be the ideal policy for you. Care Supreme is an affordable policy that covers most bases. This policy can be purchased by people as old as 99 but with benign pre-existing diseases such as hypertension, diabetes, etc. Like any comprehensive plan, it doesn’t have co-payments, room rent restrictions, or disease-wise sub-limits, and it also covers AYUSH and domiciliary treatments without any sub-limits.
Drawbacks: It has a slightly high complaint ratio and a long four-year waiting period for pre-existing diseases. However, the waiting period can be reduced with an add-on.
3. Niva Bupa ReAssure 2.0: Niva Bupa ReAssure 2.0 has three variants—Bronze, Titanium, and Platinum— with the main differences being the waiting period for pre-existing diseases and the limit for the no-claim bonus (Booster). ReAssure 2.0 also offers extensive coverage with no copayments, disease-wise sub-limits, or room rent restrictions and includes daycare, AYUSH, and domiciliary treatments.
Drawbacks: ReAssure 2.0 has a significantly higher complaint ratio than its peers.
4. Aditya Birla Activ One: Activ One offers coverage without any disease-wise caps. This is also one of the very few policies that provides a base cover of up to ₹ 6 crore! Activ One also has several variants catering to a wide range of people, which can be both an advantage and a disadvantage. Aditya Birla also offers several add-ons to further customise the policy as per your needs.
Drawbacks: Being a fairly new entrant into the health insurance industry, Aditya Birla seems to tick all the boxes while framing the policy. However, as an insurer, we feel they can have slightly better metrics, and we hope they will achieve this soon.
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Conclusion
While we don’t advocate for disease-wise sub-limits, they can be slightly beneficial for some policyholders because they reduce the premium. However, remember that you will have to pay out of pocket when making a claim if the treatment cost is more than the sub-limit.
As always, feel free to compare different health insurance policies carefully. If you still need help, consult a trusted advisor to find the best plan for your needs and budget.
