Disease-Wise Capping
Disease-wise capping refers to the point where you purchase a group health insurance plan with a particular amount of sum insured, let’s just say Rs 5 lakh. Out of this amount, the insurer restricts the maximum payout for a particular set of illnesses up to Rs 1 lakh. In simple words, if the insured raise a claim for more than Rs 1 lakh for a particular set of treatment, they will have to pay the rest of the amount out of pocket.
Here is an example, Rohan is an employee of a tech company. He is working with that company for the past 2 years and he is covered under the group health insurance plan.
In 2019, Rohan’s right eye started itching and he started having a problem with his vision and after some time the eyes started watering. He goes to the doctor for a check-up. The doctor said that he has to get treatment for conjunctivitis but during the check-up doctor also notices that Rohan has developed a cataract in the right eye.
Rohan goes for the surgery and the final billing amount totalled Rs 30,000. Rohan thought that the group health insurance plan would cover the whole amount but little did he know that the disease-wise capping for cataract surgery was set at Rs 20,000. Now the group health insurance provided coverage for Rs 20,000 and Rohan has to pay the rest of the Rs 10,000 out of pocket.
Illustration of Disease-wise Capping Slabs
In the table below we have mentioned the disease-wise capping slabs. They are as follows:
|
Lower Sub-limits
|
|
Diseases
|
Metro
|
Non-Metro
|
|
Appendix
|
12,000
|
10,000
|
|
Eye related
|
17,000
|
15,000
|
|
Gall Bladder
|
15,000
|
15,000
|
|
Hernia
|
12,000
|
10,000
|
|
Hydrocele
|
7,000
|
5,000
|
|
Hysterectomy
|
20,000
|
17,000
|
|
Piles
|
10,000
|
7,000
|
|
Kidney Stone (inc DJ stent removal for same stone)
|
30,000
|
25,000
|
|
Joint Replacement including Vertebral joints
|
75,000
|
70,000
|
|
Standard Sub-limits
|
|
Diseases
|
Metro
|
Non-Metro
|
|
Appendix
|
20,000
|
18,000
|
|
Eye related
|
25,000
|
22,000
|
|
Gall Bladder
|
22,000
|
22,000
|
|
Hernia
|
20,000
|
18,000
|
|
Hydrocele
|
15,000
|
12,000
|
|
Hysterectomy
|
28,000
|
25,000
|
|
Piles
|
18,000
|
15,000
|
|
Kidney Stone (inc DJ stent removal for same stone)
|
35,000
|
30,000
|
|
Joint Replacement including Vertebral joints
|
85,000
|
80,000
|
|
Higher Sub-limits
|
|
Diseases
|
Metro
|
Non-Metro
|
|
Appendix
|
24,000
|
19,000
|
|
Eye related
|
30,000
|
25,000
|
|
Gall Bladder
|
30,000
|
25,000
|
|
Hernia
|
24,000
|
19,000
|
|
Hydrocele
|
18,000
|
14,500
|
|
Hysterectomy
|
34,000
|
29,000
|
|
Piles
|
19,000
|
15,500
|
|
Kidney Stone (inc DJ stent removal for same stone)
|
40,000
|
35,000
|
|
Joint Replacement including Vertebral joints
|
110,000
|
90,000
|
*Sub-limits mentioned in the table are for reference purposes, actual sub-limits may vary as per the insurer's underwriting guidelines.
Here is another case scenario, Mr. Rahul, covered under Group Health Insurance, goes for Knee Joint Replacement Treatment in Mumbai. The treatment was successful, Mr. Rahul submitted a claim of Rs 1,50,000 to the Group Health Insurance Company. Mr. Rahul's Group Health Insurance Policy had a Diseases-wise Capping with Lower Sub-Limits which resulted in an out pocket expense for him with proportionate deductions as per the sub-limits.
Now you must be able to understand the concept of disease-wise capping. This is why it is advised to purchase group health insurance with no disease-wise capping so that the employee does not have to pay any amount out of pocket.
Conclusion
The purpose of purchasing a group health insurance plan is to provide healthcare benefits to the employees as well as their dependents so that they do not have to pay out of pocket. But in the case of disease-wise capping if the final billing amount crosses the capped amount then the employee has to pay for it out of pocket that kills the whole purpose of offering group health plan. So while purchasing the group health plan, make sure that there is no disease-wise capping limit so that the employee does not have to worry about any kind of expense.
