Best Answer
Srinivasan Mahadevan answered 4 years ago
Disease-wise capping refers to the maximum amount an insurer will pay for specific diseases under a health insurance policy. These caps are set either as a fixed amount or a percentage and are decided at the inception of the policy. If a claim arises for a capped disease, the insurer will approve the cost only up to the predefined limit.
Insurers commonly apply these caps to frequently occurring or high-cost treatments in group health insurance plans to manage claim ratios and keep premiums affordable. Conditions such as cataract, hernia, piles, hydrocele, renal stones, appendicitis, hysterectomy, knee or hip replacement, PTCA, CAG, TURP, and others may be subject to such limits.
For example, cataract and hernia surgeries may be capped between ₹10,000 and ₹50,000, while other procedures may have caps ranging from ₹10,000 to ₹1,00,000, depending on the plan design.
These caps help insurers control claim costs and maintain sustainable premiums at renewal.
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