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How cappings works in a claim?

QuestionsCategory: Group Health InsuranceHow cappings works in a claim?
default avatarPlan Cover Staff asked 2 years ago
1 Answers

Best Answer

default avatarSrinivasan Mahadevan answered 2 years ago
Types of capping in health insurance is capping on Room rent: room rent capping means as per policy sum insured some percemtage of amount decides for room rent in hospitalization claim upto that capped amount would be payable under health insurance.Example : if a person has a policy with an insurance company where room rent cappings are also applicable i.e., 1% of the sum insured per day; and if the sum insured is Rs. 3,00,000 and the total room rent charged is Rs. 20,000 for 4 days, then the amount payable will be Rs. 3000 per day.
Co payment: As per policy terms or plan opted at the time of policy inception co payment is applied on the claim co payment some percentage of amount decides at the time of policy inception and it applies on the claim whether it is cashless or reimbursement claim payable amount. example if any policy has a capping with a co payment amunt i.e. 5%,10%,15% 20% of the payable amount then capped amout will be deduct at the time of claim payment.Capping on maternity Cost :Maternity is normally not covered and has a waiting period of 9 months and claim from Day1 is not possible. Some Policies have a 3-year waiting period or lesser. The logic is that from the date of inception of the Policy,maternity coverage is not possible and therefore it varies from policy to policy. 9 month waiting period means that if there is a claim in this period it will not be covered.
However, for Group Insurance wherever we pay an extra loading on the premium – this 9-month waiting period is waived off Normally standard limits for C Section and Normal deliveries are not specified and vary depending on the specific T&C of your Policy. Normal Cost are always lesser as Hospitalisation is limited to 1-2 days only. C Section deliveries are those where there is a surgery involved in the delivery process.
Disease Wise Capping:- Disease wise capping means only capped or restricted amount will be paid Disease are not specified and vary depending on the specific T&C of your Policy plan.But some Standard health insurance policies has disease which are by defult in the policy plan. Cataract, Hernia,Calculus,Piles,Joi