I increased my health cover in the current year, from ₹3 lakh to ₹5 lakh. The Policy has waiting periods for certain surgeries for the enhanced amount. It also has limit on reimbursement of the claim for room rent (@1 per cent of the sum insured ) and  thus this limit of 1 per cent also applies to all the other medical costs.

My query is, for the old diseases (covered for the past 10 years), how do I calculate the 1 per cent limit — Is it still to be taken at the rate of 1 per cent of old policy amount of  ₹3 lakh, or is it 1 per cent of the revised “sum insured” policy amount of ₹5 lakh, for which the additional premium was charged?

Sunaina

When a policyholder decides to increase the sum insured for his/her health policy and subsequently makes a claim for a pre-existing disease (PED), various factors come into play regarding claim settlement.

One crucial consideration is the room rent. The room rent for hospitalisation will be settled in accordance with the specific product’s room rent limit, if applicable, as per the revised sum insured. This implies that with an increase in the sum insured, the customer may become eligible for a higher room rent limit, thereby gaining access to better accommodation during hospitalisation.

However, despite the increase in the sum insured, particularly for claims related to pre-existing diseases, there remains a maximum limit for claim settlement as per the old sum insured, in case the sum insured is exhausted. In essence, even if the customer has elevated the sum insured, there exists a cap on the amount that can be claimed for pre-existing conditions, which corresponds to the previous sum insured. Once this limit is reached, any further expenses related to the pre-existing condition claim will not be covered by the policy.

It’s noteworthy that to avail coverage under the new sum insured, an applicable waiting period must be served. Once the waiting period for the new sum insured is completed, the coverage under the new sum insured will come into full effect, including any alterations in disease capping or coverage limits associated with the new sum insured.

Given the intricacies involved, it’s crucial to meticulously review your insurance policy documents and consult with your insurance provider for specific details regarding waiting periods, coverage limits, and any other terms and conditions applicable to your policy.

The writer is Assistant Vice-President & Head - B2B Business, InsuranceDekho.com

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