The continuous inflation in the healthcare industry has made it difficult for people to access good healthcare treatment at reasonable cost. This is especially in case of people whose income range is between low to medium. Hence, the need of a comprehensive health insurance plan is necessary to bear such expenses. However, just choosing a plan without proper knowledge about the same as well as without understanding the terminologies of the policy won’t benefit you much. One such important jargon to know about is copay in health insurance.
In general, people procure health insurance with the certainty that the insurance company will cover their bills/claims up to 100%. Now, assume that you went through a treatment and was hospitalized for the same. The total expenses of the treatment and hospitalization came to INR 10 lakh. You raised a claim for the expenses with the insurer assuming that you would be reimbursed for the same. Now, the insurer informs you that you have to pay 5% of the bill from your pocket, while the remaining amount will be paid by the insurer. This means that you will have to pay INR 50,000 from your pocket, which is not a small amount. You question your insurer about this charge and find out that they have laid a co-pay clause under the policy as mentioned in the policy document. So, even if you don’t remember any such clause while buying the plan, it is mentioned in your policy document. Such cases are not surreal in the insurance industry as they keep happening. So, let’s understand the co-pay meaning to understand it well.
Co-payment means a particular percentage of claim amount that an insured person has to pay at the time of claim settlement for a medical treatment. So, if there is a co-pay clause in your health insurance, you will have to share a portion of the hospital bill with the insurer while raising the claim.
Hence, it is important to check the co-pay clause to understand the exact amount you would have to contribute at the time of claim settlement.
In some cases, health policies might come with mandatory co-payment clauses. On the other hand, some plans allow the insured person to choose a voluntary deductible. This also reduces the premium amount to some extent. Overall, co-pay depends on the insurance policy and the insurance company that you buy the plan from. The co-pay percentage that a policyholder needs to pay varies between 5% to 20%.
There are different types of co-pay clauses and insurance companies apply such clauses as per different scenarios. Some such clause include;
Insurance companies put a co-pay clause in case of critical illnesses or pre-existing diseases etc. because the treatment for such conditions is too high. Hence, the insured has to pay a portion of the copay in medical bill
Insurers, in many cases, levy a co-pay clause under reimbursement claims. So, if you choose to get treatment at a non-network hospital where you cannot have cashless claims, you may be levied with a co-pay clause.
We already know that the treatment expenses of people increase with age. The more the age of a policyholder, the greater the chances of medical complications. So, to limit the risk, insurers apply the clause of co-pay in case of senior citizens.
Healthcare costs are higher in metropolitan cities as compared to other small towns and cities. Hence, looking at the higher medical expenses, insurance companies might levy a co-pay clause for metro and urban cities as compared to small towns.
Here are some features of co-pay:
| Features | Details |
| Co-pay areas | Hospitalisation, doctor visit, diagnostic tests, medicines etc.|
| Co-pay amount/portion | The insured is expected to pay a small portion as co-pay |
| Co-pay percentage | This depends on the health insurance plan and the health insurance company opted for |
| Premium | Premium depends on co-pay. The higher the co-pay, the lower the premium and vice versa |
| Applicability | Applies on higher medical expenses like treatment of elderly, treatment in metro cities, critical illness treatment and so on |
The co-pay percentage that is shared by an insured with the insurer impacts the premium of the insurance directly. This is because when the co-pay amount is high, the premium you pay is low.
If you pay a higher co-pay, it will make your premium amount low. However, you may incur higher expenses from your own pocket while raising a claim. With higher co-pay, the risk is shared between the insurer and insured.
In case you opt for a smaller co-pay amount, your premium most likely will be higher. But it will decrease your expenses from your pocket while raising a claim.
With a high co-pay, you can reduce the annual expenditure on the premium you pay. This way, you can save expenses on a yearly basis on the premium amount you pay.
Though your co-pay clause reduces the yearly premium to a great extent, you may end up paying an extravagant cost if you raise a claim for treatment. If that happens, the point of having health insurance would go in vain.
With a high co-pay, you can reduce the annual expenditure on the premium you pay. This way, you can save expenses on a yearly basis on the premium amount you pay.
Co-pay in health insurance means that a small portion/percentage of the total hospitalization cost is incurred by the insured, while the insurer covers the major portion.
The insurance co-pay clause makes it cheaper because the liability of the claim amount is shared between the insurer and the policyholder. Thus, the policy becomes comparatively cheaper.
If you are planning to buy a health policy with a co-pay clause, you should consider your health and medical condition. A healthy person who maintains a healthy lifestyle may not require to raise a claim that frequently. Hence, they can choose to buy such a policy with a co-pay clause. However, if you are not sure about your health because of your unhealthy lifestyle, you might reconsider buying a policy with a co-pay clause.
To know the details of co-pay percentage, you should go through the policy document thoroughly where all the details are mentioned including the inclusions and exclusions of policy, co-pay clause and percentage, and so on.
Co-payment health insurance means you will have to share a portion of the hospital bill with the insurer while raising a claim.
Deductible is the amount that an insured person has to pay before the insurance company covers you for the rest of the claim amount. For example, if the deductible of your insurance plan is INR 50,000, you first pay the complete amount INR 50,000 of deductible on claims and only after that amount gets exhausted your insurer pays the bills for the rest of the claims.
* Rs. 245/month is the starting price for a 5 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*! Rs. 334/month is the starting price for a 10 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*@ Rs. 12/day is the starting price for a 5 lac family health insurance for an 25-year-old male and 22-year-old female, with no pre-existing diseases.
*# Rs. 12/day is the starting price for a 5 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*$ Rs. 600/month is the starting price for a 20 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*^ Rs. 12/day is the starting price for a health insurance that covers coronavirus for an 25-year-old male, with no pre-existing diseases.
