Medical bill lower than health insurance sum insured? Here’s why you may still pay expenses out-of-pocket

A health insurance policy is one of the most essential financial products that any individual can have. However, there are certain misunderstandings about health insurance policies. One of the most common ones is that if the total medical expenses are under the amount that is covered by health insurance, the policyholder gets complete coverage.

However, this is not true. The insurance company will offer coverage up to a certain amount, beyond which you will have to cover the remainder of the expenses from your own pocket.

To understand this in a better way, let us take a look at the reasons why you do not get complete coverage from your policy even your medical bill is under the sum insured.

  1. There are certain exclusions

We often assume that each and every medical expense will be taken care of by our health insurance policy. This is not always the case as policies have certain exclusions as part of their terms and conditions. Your policy might not cover certain expenses such as admission fees, registration charges, medical record fees, insurance processing fees, and so on. Some policies might not even include doctor’s visits, but this depends on the kind of policy offered by different insurance companies.

  1. The co-payment clause

A co-payment is where you have to bear a certain percentage of the total medical bill while the rest is taken care of by your health insurance policy. Certain health insurance policies have a mandatory co-payment clause while others may keep this optional.

  1. Limit on the room rent

Most of the insurance policies have caps when it comes to the room rent. Once you cross the upper-limit on the room rent, the insurance policy will not cover the expenses beyond that limit. Let us look at an example: Raghav has a health insurance policy that has a room rent limit of up to Rs.3,000. If Raghav chooses a room that charges a rent of Rs.5,000, he would only get coverage of up to Rs.3,000 and will have to shell out the remaining amount (Rs.2,000) on his own.

  1. Sub-limits in policy

Generally, most health insurance policies set a sub-limit on many major treatment expenses. Upto that limit, the medical expenses are covered under the policy. But as soon as the medical expenses exceed that limit, you will have to pay the remaining expenses from your pocket. For example, if Raghav’s health insurance policy covers a certain day care procedure for only Rs.30,000 and his treatment actually costs Rs 50,000, he would have to pay the remaining Rs.20,000 on his own.

  1. No coverage for visitors

While you are in the hospital, your family might come to visit and even have lunch/dinner at the hospital. They might stay in hotels that are close to the hospital so that they can visit daily. But you should know that health insurance policies generally do not cover these expenses and you will have to afford these on your own.

Read More: Should I Increase My Health Insurance due to the Pandemic?

We hope this article has helped you, all the best!