Sublimit in health insurance refers to that specific condition where the insurance company will offer coverage only to a specific limit. The rest of the expenses will have to be borne by the insurance holder. The terms and conditions section clearly mentions if there is any sublimit applicable on any specific condition.

Types of sublimit in health insurance

There are three major types of sublimit in health insurance. These are:

  1. Sublimit on hospital rental charges: Sublimit on hospital rent is also quite common. The insurer may put a capping of 1% of the sum insured or a specific amount of money as per the terms and conditions of the insurance company. There can be a capping on the consultation charges, oxygen supply, ICU charges, diagnostic tests, room rental, etc. It is therefore advisable that a patient chooses that room that is fully covered under the health insurance plan despite the sublimit. This will significantly bring down the expenses which the patient or his family needs to bear.
  2. Sublimit on post-hospitalisation expenses: If a patient has undergone major surgery, he or she may need to continue with his treatment even after getting discharged from the hospital. A health insurance company, even if it has promised to cover post-hospitalization expenses, can put a sublimit on the same. In that case, the insurance holder will have to bear the rest of the expenses.
  3. Sublimit on any specific treatment or disease: Some diseases are quite common in nature, such as piles, cataracts, high blood pressure, kidney stones, etc. An insurance company has the right to put a sublimit on the treatment expenditures of such ailments. You need to check for clauses that mention that only 80% of the expenses will be borne by the insurer.

How to be vigilant enough against sublimits?

Before buying a specific health insurance plan, you are required to go through the terms and conditions carefully. Ask questions openly and know about different types of sublimit. Also, make sure beforehand that the expenses which will be lesser than the sublimits will be covered by the insurance company only.

Why is sublimit a significant part of a health insurance policy?

It is an important factor that helps you evaluate whether or not a specific health insurance plan is suitable for you or not. Also, not all health insurance plans have sublimits. You will come across certain policies where the insurer will give you the option to opt-in or opt-out of the sublimit clause. A health insurance policy that does not have any sublimit will have a higher premium charge.


Q. Is there any definite rule laid down by the IRDA regarding sublimit?

Ans: No. IRDA has not laid down any specific rule regarding sublimit in health insurance.

Q.  I have opted for reimbursement claims. Are sublimits applicable to them as well?

Ans: Yes, sublimits are put on reimbursement claims as well. Insurance companies set these sublimits, and thus these are applicable irrespective of the type of claim.

Q. Will there be a sublimit in all health insurance policies?

Ans: No, there are many health insurance policies that do not have sublimit. However, the premiums for those policies will be a tad bit higher.

Q. How can I check for the sublimits in a health insurance plan?

Ans:If you want to know about the sublimit in a specific health insurance policy, simply go through the terms and conditions section. You can also connect with the insurer and know in detail about the same.

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