Room rent capping in group health insurance

What is room rent capping in Group Insurance (Group Mediclaim)?

Hospital costs are linked to the type of room availed e.g., Doctor’s fees in single ac room would be higher than that of shared room. Hence insurance company have put conditions for room eligibility. All costs thereafter are payable as per the eligible room rent. Typical eligibility is 1% of sum assured as room rent cap.

How does health-care costs vary by room type?

Below figures, shows the cost of Single AC room and Shared Room, alongwith are mentioned the package cost of Heart By-pass surgery for these rooms respectively. These are actual costs for a leading hospital in Delhi.

Room rent per day:

•             Single AC Room: 9900

•             Shared Room: 4000

Cost of heart surgery by room type

•             Single AC Room: 292,000

•             Shared Room: 200,000

 

How does claim admissibility vary by room type?

In case the Insured person opts for a room with rent higher than the entitled category, the charges payable shall be limited to the charges applicable to the entitled category.

So if for instance, one had a health policy with sum assured of Rs 4 lacs, and a room eligibility of upto Rs. 4000, then the claim payable would be limited to Rs. 2 lacs. So despite the sum assured being much higher, the Insured would have to pay 92,000 out of pocket.

Can room rent be customized under group insurance policy?

Fortunately, one can customize the Group Health policy to choose the room rent type. Following options are available:

•             As proportion of Sum Assured (1%, 1.5%, 2%)

•             Single AC room (irrespective of the costs)

•             No room rent capping at all

Conclusion

It is recommended for employers to choose an expert professional to design the Group Insurance policy.

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