Group Health Insurance

If you have a group health insurance policy, the insurer will apply capping or sub-limit clause. Capping refers to the limit, usually, a percentage up to which the insurance will settle the claim for different hospital expenses.

Here are some of the expenses which are capped in a group health insurance policy –

  1. Room Rent: Usually, most of the group health insurance companies keep it as 1% of the sum insured per day. In some situations, it may also be the fixed amount per day.
  2. ICU Charges: Most of the group health insurance companies put the capping on ICU charges as 2% of the sum insured per day, or even a fixed amount is paid as mentioned in the policy document.

Read More: How to File a Claim Under Group Health Insurance Policy?

  1. Ambulance Charges: Here the capping may vary from one insurer to the another. Some group health insurers cap ambulance charges for a specific amount per hospitalization. Here, the sub-limit will be on the number of visits and the amount per visit. Then there are some health insurance companies which put a cap on the number of amounts that can be availed in the form of ambulance charges in a year. There is no restriction on the number of However, capping is the maximum amount that one can avail as ambulance expenses.
  2. Maternity Charges: Almost every insurer has defined a waiting period for covering maternity related expenses. A fixed amount is defined in policy for maternity benefits and any expenditure over it to be borne by the policyholder.
  3. Attendant Allowance: Most of the group health insurance companies have the provision of giving daily hospital allowance for the person accompanying an insured child. There is a cap on the maximum amount that can be availed as an attendant allowance under a group health insurance.
  4. Certain Medical Procedures: Just like the above procedures, a group health insurer also places a cap on the amount which can be claimed with respect to the hospitalization of certain ailments, like a cataract. Usually, it is decided on the basis of the sum insured, and it is a fixed value for certain ailments or sometimes expressed as a percentage of the sum insured.

It is not an exhaustive list as there are other expenses as well on which a group health insurance company can put a capping on the amount.

Capping defined in group health insurance policies vary from one insurer to the another. Just as it is necessary to know what is included in a group health insurance policy, it is equally necessary to know these capping to make yourself ready for the expenses which you would have to pay from your pocket.

Case: 1

Working in M.J Software, Jivesh Mehta was covered under a group health insurance policy offered by its employer. A few months ago, Jivesh had to go for knee replacement in a private clinic, where the medical bills came to Rs 3 lakh. Of this, Mr. Mehta’s group health insurance policy had a cap of Rs 50,000 for knee replacement surgery. When Mehta approached the group health insurer for the claim settlement, the insurer settled Rs 2,50,000, and the remaining Rs 50,000 would have to be borne by Jivesh itself.

Read More: What Are Additional Benefits Available Under Group Health Insurance?

Case: 2

Mrs. Meenal Jain was working in an G.A Housing Company who was offering group health insurance policy to its employees. Around one year before her retirement, Meenal got her cataract surgery done. Her total surgery expenses came around Rs 30,000. In this case, her group health insurance company had a capping of Rs 5,000 on cataract surgery and therefore, the insurer paid Rs 25,000, and the remaining Rs 5,000 had to be paid by Meenal.

Case: 3

L.W Engineering is offering a group health insurance policy with a sum insured of Rs 5 lakh. However, the policy has a capping on room rent charges as 1 % of the sum insured. It means, if any of its employees is hospitalized, he/she can stay in a room with charges of Rs 5,000. In case, if a costly room is chosen, the insurance company will not pay additional room rent, and the cost has to be borne by the employee itself.

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