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What is a Co-Pay health insurance plan?

By Naval Goel
December 18, 2015 10:45 IST
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With the ever rising medical expenses, a health insurance plan has become MUST.

And due to expensive hospital facilities and treatment, the cost of health insurance plan is also getting higher.

A co-pay option offered by many insurers can help reduce the cost of a health insurance plan and its premiums.

Here we will discuss the different aspects of co-pay and your health plan.

What Exactly Is Co-pay?

With a co-pay plan, the policyholder agrees to pay a proportion of the health plan claim.

The fraction of the co-pay lies between the ranges of 10 – 25 per cent. In this, the policyholder has to pay his/her share of the claim first and then the insurer will settle down the rest of amount up to the limit of the specified health insurance plan.

Let us take an example to understand the same.

Suppose you have 30 per cent co-pay option in your health plan and your claim is for Rs 1 lakh. In this case, you have to pay Rs 30000 first and then your health insurance plan will cover the balance amount.

Advantages of Co-pay

The major benefit of the co-pay is the low premium amount.

For e.g., if you opt for 30 per cent co-pay, then your premium will be lower by up to 30 per cent.

Co-pay provides benefits if there is no hospitalization in the entire policy period.

In case of hospitalization, then the policyholder has to pay his/her share of the health policy.

Co-Pay Plans

There are different types of co-pay policies are available in the market:

Type of services

There are some insurance companies which charge higher co-pay if the policyholder selects higher class of services such as deluxe suite.

Hospitalization in cities:  Hospitalization costs in metro cities are higher. Some health insurance plans do not require co-pay in case of non-metropolitan cities. But if a policyholder is getting hospitalized in a metro city, then he/she have to pay a portion of the claim.

Non-network hospital: In the case of treatment in non-network hospital, some health insurance plan requires co-pay. You must pay attention towards the same while you are selecting a hospital. It is advisable to contact your insurer before getting hospitalized to confirm whether a particular hospital is empanelled with the insurance company or not.

Treatment in expensive hospital: Some insurers categorize certain hospitals as expensive. Treatment in these hospitals may require higher co-payment. It also depends upon the rules of the mediclaim policy. The policyholder should confirm the same before making any commitment to the insurer.

Pre-existing disease: You must be aware that in some health insurance plans, pre-existing disease are excluded from the coverage for at least 3 years. Subsequently the policyholder can claim for treatment of pre-existing disease, but such treatments require co-payment from the policyholder.

Should you select co-pay?

If you are already covered under a floater health insurance plan, then you don’t have any option. You will be bound by the contract related to co-pay. The norms related to co-pay depends upon the company.

It is advisable for youngsters to opt for co-pay as they can save more on health insurance premiums. Over a period of time, the cost saving can be quite generous.

Senior citizens with some medical issues should not opt co-pay, this is because the cost of their medical expenses will be higher that will directly increase the co-pay amount.

Co-pay helps in reducing the health insurance costs. You should check the pros and cons of health insurance plan with co-pay before buying it.

A standard format related to the co-payment clause is available in the documents of health insurance plan.

Therefore, it is advisable to read the documents of the plan carefully. This will help you in understanding different requirements of the co-payment clause.

Illustration: Uttam Ghosh/

Lead image used for representational purposes only.

Naval Goel is CEO and Founder,

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Naval Goel