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Cost Limit in Health Insurance Claim Research Team | Posted On Wednesday, September 04,2019, 04:59 PM

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Cost Limit in Health Insurance Claim



Why do you need health insurance? Well, if you want to stay free from the worries of high medical bills, you need a health insurance plan. In these days of changing lifestyle habits and high pollution; the health insurance plan protects you from health conditions and disease.

You enjoy cover against critical illnesses, the cashless claim benefit, additional protection over and above employer cover and even tax benefits under Section 80D on health insurance premiums. This is for health insurance premiums paid for self, spouse, kids and parents. You are covered for hospitalization expenses, day care treatment, domiciliary treatment and even ambulance charges.

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Cost Limit in Health Insurance Claim

Sum Assured: Sum assured in health insurance is the maximum amount payable by the insurer to the policyholder if he/she is hospitalized. This is in-line with terms and conditions of the health insurance plan.

A health insurance policy with a sum assured of Rs 2 Lakh will only settle the claim up to this amount; on a hospitalization or daycare treatment as specified under the plan. If the total medical bill exceeds Rs 2 Lakh, you have to bear the remaining amount, out of pocket. It would be good if you opt for a high sum assured in health insurance to stay protected from high medical bills.

See Also: Why Does One Need Health Insurance Policy?


Deductible is the amount that you (policyholder) have to bear, before the insurer bears the medical bills. The insurer has to pay the claim amount only if it exceeds the deductible.

Let’s say you have specified the deductible at Rs 30,000. The insurer becomes liable to pay the medical bills only when the deductible of Rs 30,000 has been exceeded. If the claim comes to Rs 40,000, the insurer pays (Rs 40,000 – Rs 30,000) which is Rs 10,000. If the claim is for Rs 20,000 you bear the medical bills yourself as the deductible is not exceeded.

Network: Insurers have a tie-up with hospitals called network hospitals. It is good to get treated at a network hospital as you enjoy the cashless claim facility.

Pre-Existing Medical Conditions: A pre-existing medical condition is defined as any disease, injury, sickness or mental, nervous and physical condition which exists at the time of purchase of the health insurance plan. Terms and conditions vary across insurers vis-a-vis pre-existing conditions.

See Also: Limitations in Health Insurance Policy

Waiting Period: Waiting period is defined as the period during which claims are not settled. The waiting period may be the initial waiting period, pre-existing condition waiting period and waiting period for pregnancy.

Most insurers offer health insurance with an initial waiting period of 30-90 days. People suffering from pre-existing medical conditions have to wait for around 2-4 years before these diseases are covered. A few insurers offer maternity benefits after a waiting period of 9-48 months.  

Sub-Limit: A sub-limit is a monetary cap on medical insurance claim. You would find sub-limits on hospital room rent, doctor’s fees, ambulance charges and pre-planned medical procedures like cataract removal, knee ligament construction and so on.

See Also: Exclusions of Health Insurance Policy

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