Here’s What You Can Do When You Exhaust Your Health Insurance Sum Insured

There’s no telling when medical emergencies can happen, how severe those would be or if you will need hospitalisation for another ailment in the same policy year. Even if you have health insurance, some medical treatments are so expensive that they exhaust the sum insured in no time. You may not have sufficient funds for another medical emergency if one arises. However, you need not worry about such situations. Compare health insurance plans and opt for one with the restoration add-on feature. If the sum insured is exhausted, the insurer will refill it to the original amount so that you continue to be protected. 

Why is the Restoration Benefit of Health Insurance Useful?

Also called a refill benefit, if policyholders are hospitalised again in the policy year, they can use the amount that the health insurance companies add as soon as the sum insured gets over when a claim is raised. This backup money also comes in handy if you are unfortunately struck with two different ailments in the same year, resulting in eye-watering medical bills. Consider this: given the ongoing COVID-19 pandemic, one could be afflicted with the virus, which can need an additional hospital stay apart from any other illness or an accident. 

Types of Restoration or Refill Benefit

Restoration benefits are also available as health insurance add-ons/riders in many cases. Primarily, there are two types of health insurance restoration benefits that insurers provide: 

Complete Exhaustion

If a policyholder exhausts the entire sum insured, the insurance company gives this type of restoration benefit for the person to fall back on. For instance, if you have a sum insured of INR 8 lakhs, raise a health insurance claim of INR 7 lakhs when hospitalised, and need the second hospitalisation in the same policy year, you cannot avail of the restoration benefit with the balance of INR 1 lakh. Only when you use the whole INR 8 lakh sum will you get a refill. 

Partial Exhaustion

Even if you consume only a part of the sum insured, health insurance plans will provide you with restoration benefits, which is undoubtedly a better and more beneficial type. For example, if you have INR 1 lakh remaining from the sum insured, it will be refilled to INR 8 lakhs, and the restoration benefit will apply. This will be at your disposal for future claims.

Note - The restoration type you get depends on the insurance company. Read your health insurance policy document thoroughly for the restoration benefit and other details.

Whom is the Restoration Benefit Ideal for?

This add-on will benefit you whether you have an individual policy or family floater health insurance plan. However, it primarily helps those with family floater health insurance policies as it adds value to the policy. The sum insured is more likely to be over if more than one family member needs hospitalisation in the same policy year. This is because the sum insured in a family plan is divided among the members. If one person’s hospitalisation takes up all INR 5 lakhs of the insured sum, there might be nothing left for another emergency in the family. 

How Can You Opt for Restoration Benefit?

The restoration benefit is an in-built feature of most health insurance plans. In case your policy does not have this feature, and you have claimed quite a bit, consider switching to another insurer offering this facility. Switching requests are entertained at least 45 days before the renewal date with the existing insurance company. Also, some insurers provide it as a rider for an extra premium. No matter which option you choose, read the policy documents closely as many conditions apply to the same. 

Things to Keep in Mind when Getting a Restoration Benefit

Beneficial as a refill is, the feature comes with many terms and conditions. These include: 

• The insurer will restore the total sum insured even if you consume it in one claim during the policy term.
• You cannot carry forward the refilled amount to the following policy year, whether or not you use it up at the restoration time.
• You may use the restoration benefit only for future claims, not the first one in a policy year.
• The restoration benefit is available to only one person at a time.
• Refill benefit applies to any amount of sum insured and not just higher sums.
• You cannot use the restoration benefit for the same ailment the second time of hospitalisation. It applies to different diseases. However, if your family member has the same medical emergency as you, they will continue to be covered, but it should be at different periods.  

Note - Terms and conditions pertaining to the restoration benefit can differ from one policy to another. So while we have briefed you on the restoration benefit, check your health insurance policy for exact terms and conditions.

Conclusion

One can have multiple medical emergencies in a year, and the sum insured often gets exhausted. With the restoration benefit offered under health insurance plans, you can automatically get a refill of the entire amount once it’s depleted. Be mindful of the conditions that apply to this benefit, and it will hold you in good stead. 

Read more-

• Are You Aware of Health Insurance Restoration Benefits
• Are Congenital Diseases Covered by Indian Health Insurance?