• What is Co-Pay in Health Insurance?

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    So you’ve taken a health insurance policy and unfortunately the time has come to claim it. You go the hospital, get checked up, treated and are presented with a bill. Typically, the health insurance company will take care of the entire expense as per the terms of your policy, and you will walk out healthier, and just as rich as you were when you were admitted in the hospital. But this isn’t the case with co-pay.

    What is Health Insurance Co-Pay?

    If your insurance policy has a co-pay clause, you will agree to pay a part of the medical expense out of your own pocket, and the insurer will cover the rest. There are many insurance companies today (like United India Insurance Company, New India Insurance Company, SBI General Insurance, etc.) that have co-pay clauses in their policies. The co-pay amount is usually a fixed amount for different services and drugs, varying depending on the nature of treatment or medication required.

    For example: If your insurance policy has a co-pay (or co-insurance) clause of 10% and your medical expenditure has totally amounted to Rs.50,000, you will have to pay Rs.5,000 out of your own pocket and the insurer will cover the remaining Rs.45,000.

    Features of Co-Pay Health Insurance:

    • It is an amount paid (or a percentage of the total) for certain medical treatments and medication, while under the cover of the insurance policy.
    • A part of the expense is taken care of by the insured, and the majority is paid for by the insurer.
    • By definition, it’s a different fixed amount that’s charged depending on the medical service rendered.
    • The terminology is used interchangeably with “co-insurance”. But means the same thing here in India.
    • Larger co-insurance and co-pay ratios in favour of the insurer mean lower premiums for the insured.
    • Mostly applicable to senior citizens in health insurance policies in India.
    • Co-pay policies are more prominent in major established cities.

    How is Co-pay different from Co-insurance?

    The term health insurance co-pay is generally used interchangeably with co-insurance. The primary difference between co-pay and co-insurance is that under co-insurance, the insurer and the insured enter into an agreement where each party agrees to pay a percentage of the total cost. The co-insurance percentage is represented as 90-10, 70-30, 80-20, etc. depending on the agreement, with the insurer’s contribution written first and the insured person’s contribution second. Co-pay is the fixed amount paid for different health care services. These terms are used interchangeably here in India, by all major insurers to mean the sharing of risk and liability.

    Why do insurance companies have co-pay clauses?

    Apart from the obvious reason that the insurance company will be able to save a portion of its expense during claims, insurance companies also have co-pay clauses for the following reasons:

    • Discourages people from making unnecessary claims, as they will have to pay a portion of the expense. Claims for medication and treatment sought to get over the common cold, or for some kind of regular gastric distress, could technically be charged back to the insurer. This results in a lot of unnecessary paperwork for both parties and a minimal claim amount. Co-pay discourages the misuse of health insurance policies.
    • Discourages people from undergoing treatment in expensive hospitals and healthcare centres. Assume you have an insurance policy with a co-pay (or co-insurance) clause of 10%. Treatment for a health condition at a regular hospital may come up to Rs.10,000, the insurer will pay Rs.9,000 and you will only have to pay the remaining Rs.1,000. But if the medical treatment has been sought at an expensive hospital/institution, the total expense for the same treatment could be as high as Rs.40,000 (recent polls suggest that boutique hospitals, high-class medical centres and speciality centres charge up to 40% more for the same services and treatments). This means that you will end up paying Rs.4,000 out of your own pocket. This will discourage the average insurance holder from wasteful expenditure at more expensive hospitals.
    • Encourages honest and judicious use of health insurance policies. The fact that co-payment means you will have to pay an amount out of your own pocket, means that you will see your hospitalization or medical treatment as an expense that you must incur as well. This will ensure that you use it right, as it brings with it a sense of ownership.
    • Mitigates the risk and liability for the insurer. Insurance companies are huge businesses with huge profit and loss statements. What increases the balance in the loss column are payments made due to claims. A co-pay (or co-insurance) clause of 10% in all its policies means a direct 10% saving for the insurance company.

    What are the disadvantages of co-pay?

    Not every insurer in India chooses to add a co-pay clause to the insurance policy they sell you. This is because of a multitude of reasons, both in favour of the insurer and the insured:

    • If the co-pay amount is too high it may deter the insured person from seeking life-saving medical attention and care – thus rendering the insurance policy completely useless. A person who has to pay a high amount of co-pay is pretty much un-insured, as the whole purpose of the insurance policy is defeated. Many of those who can’t afford basic healthcare anyway would be at a huge disadvantage, and will be paying premiums for absolutely no reason, if they can’t get adequate financial aid from the insurer in times of need.
    • Medical insurance products and policies offered with co-pay are generally less popular, and less likely to be bought. A person who understands co-pay and co-insurance would choose a policy that does not have such clauses. An insurer who offers to pay the entire medical expense will have better products and higher sales simply because of that fact.
    • Higher co-pay means less premium. While this is true, it is only beneficial for the insured person (you), as long as you don’t need to cash in your insurance policy. But if something happens, all that money you saved on premiums will have to paid towards the treatment expenses anyway.

    Is a health insurance policy with co-pay the right choice for you?

    Health insurance policies today are expensive, and serve to do more than just cover hospital bills. The policies and premiums paid can be used to save on taxes, and act as a safety net. As a general rule, better policies come at a greater premium cost. And this premium cost can be discounted, if you opt for an insurer offering a co-pay policy.

    If you are a person in the prime of health and good physical condition, without a history of past diseases, pre-existing illnesses, or any susceptibility to falling critically ill in the future, a co-pay policy could enable savings for you. You will not need to cash in the entire policy, and can make use of the many benefits that come with it.

    For example:A person will end up paying up to 10%-20% off on a health insurance policy taken from a provider who has a co-pay clause, as opposed to one that does not. An insurer without a co-pay clause will be taking all the risk on themselves, hence demand higher premium payments. National Insurance Co. Ltd. has a co-pay scheme that offers 10% discount on premium on acceptance of a 2% co-pay clause.

    FAQs about Co-Pay in Health Insurance:

    1. What is co-pay health insurance?

      Co-pay health insurance is a type of insurance where a small portion or percentage of the total hospitalization is paid by the insured person, and the insurer covers the major portion.

    2. Why do people opt for co-pay health insurance?

      People opt for such policies as they reduce the burden of large premium payments and are cheaper than other health insurance policies.

    3. Which health insurance providers in India have co-pay health insurance policies, and at what percentage?

      There are many health insurance providers in India with co-pay policies. Some of them are:

    4. United India Insurance Co. Ltd. 20% co-pay for senior citizens, on critical illness.
      New India Assurance Co. Ltd. 10% co-pay for claims from pre-existing medical conditions.
      Oriental Insurance Co. Ltd. 10% co-pay.
      National Insurance Co. Ltd. 10% discount on acceptance of 2% co-pay policy.
      SBI General Insurance Co. Ltd. 10% co-pay.
      Future Generali India Insurance Co. Ltd. 30% co-pay for customers in Zone-A (Mumbai, Delhi, NCR) and 20% co-pay for those in Zone-B (Chennai, Kolkata, Bangalore, Ahmedabad, Hyderabad). No co-pay for remaining areas.
      L&T General Insurance Co. Ltd. 10% co-pay for those above the age of 80.
      Bajaj Allianz General Insurance Co. Ltd. 10% co-payment in non-network hospitals which can be waived off on payment of an additional 10% of loading on premium.
      Universal Sompo General Insurance Co. Ltd. 20% co-pay for those above the age of 55.
    5. Why are insurance policies with co-pay cheaper?

      The risk and liability of paying off a claim is divided between the insurer and the insured, hence the policy is cheaper.

    6. Should I take a policy with co-pay?

      You must consider your present and past medical condition, and physical state, before deciding to take or not to take a co-pay health insurance policy. If you are healthy, maintain a healthy lifestyle with diet and exercise, and do not feel that you may need to cash in your insurance – take a co-pay policy. If you lead an unhealthy lifestyle, have a susceptibility to medical conditions, and feel you may need to cash in your insurance at some point – take a regular health insurance policy.

    GST rate of 18% applicable for all financial services effective July 1, 2017.

    Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.

    Co-Pay Reviews

  • Page 1 of 50 1 2 3 4 5
    • Max Bupa Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have my health insured with MAX BUPA from last 3 years and it is one of the good policy. It is a family coverage where spouse and children are covered. I pay a premium of Rs 18000 for this health insurance. My claim experience was good and they covered 70% of the billed amount.
      Was this review helpful? 0
      , bangalore
      Reviewed on Jun 19, 2018
    • Religare Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I was using health insurance policy with Religare from last 2 years, i am happy with the coverage value of this insurance policy. I am satisfied with the claim experience and it was a cashless treatment. I have a coverage value of Rs 3 lakhs for this insurance policy.
      Was this review helpful? 0
      , navi mumbai
      Reviewed on Jun 19, 2018
    • ICICI Lombard Health Insurance
      "Good Policy"
      0.5 5.0/5 "Blown Away!"
      I took health insurance from Icici health insurance . I have choose this insurance mainly because of convincing premium with too many benefits . This policy covers Cashless hospitalization. Pre diseases coverage . Overall am satisfied with customer care and service. Am getting income tax benefits
      Was this review helpful? 0
      , new delhi
      Reviewed on Jun 19, 2018
    • New India Health Insurance
      "Very good service"
      0.5 5.0/5 "Blown Away!"
      New India Assurance was the first health insurance provider with the Employer provided health insurance, They've partnered with the many hospitals in Pan India and also offered protection for the entire family. They were also offering cashless treatment facilities. Overall it has been a smooth experience.
      Was this review helpful? 0
      , chennai
      Reviewed on Jun 18, 2018
    • SBI General Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have a health insurance with SBI general insurance from last 2 years, i am happy with the coverage value of this insurance policy. I have not claimed anything so far from this insurance company. I pay a premium of Rs 50 per month for this insurance policy.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Jun 18, 2018
    • Star Health Health Insurance
      "Good to have insurance policy"
      0.5 3.0/5 "Satisfactory"
      Idon't have any experience of claim hence i never get a chance to call their customer care. They used to call me for renewing the policy. I can claim about 3.5 lakhs per annum. If i use 10% or not claim the policy, they wont give additional benefits for the next year. Their is a insured amount by 10%. My premium amount will be same but the claim amount they will increase by 10% next year. Cashless treatment is available in this policy
      Was this review helpful? 0
      , noida
      Reviewed on Jun 18, 2018
    • National Insurance Health Insurance
      "Very late back policy"
      0.5 3.0/5 "Satisfactory"
      My company people have taken health insurance policy to the employees. Once i have claimed the policy for my mother. The service is not good as per experience. They have a separate hospital list, in that they have mentioned cashless facility is available but when i went for those hospital, they said their is no cashless facility for this insurance. They will not response from the National Health insurance. The number will keep on ringing. After that my company asked me to send the bill. But i never done to this company. The claim is very low which is less than 20000.
      Was this review helpful? 0
      , bangalore
      Reviewed on Jun 18, 2018
    • Religare Health Insurance
      "BEST"
      0.5 4.0/5 "Great!"
      From past 7months i am using this health insurance. Documents i have done through the on line. The coverage is for 10k. Per annual i pay of rupees 7-8k. Disease coverage is there. Free medical checkup once in a year is also available in my insurance.
      Was this review helpful? 0
      , new delhi
      Reviewed on Jun 17, 2018
    • New India Health Insurance
      "Chatting with customer at clamp time"
      0.5 0.5/5 "Unacceptable"
      This is a type of fraud company.This does not pass the claim.When they go to the customer to make a claim, it only rotates it, this time of direction can be more than 8 months.thay do not have any response anymore, only you have to call them these times and you have to consider the information.Out of which it does not raise your phone more than half the time. Each time they constantly ask for something new, they never tell you once and after 8 or 9 months of the final, you cancel your claim according to the new rule.They do not deliberately describe the whole processor, either by either losing the customer tired or in the last. I will request all individual personal and special corporate offices to never do any bonding with this type of company.Because the new rules which it says in 8 or 9 months, how will the customer know at first sight, they deliberately conceal the rules so that the customer does not get disturbed and do not claim.
      Was this review helpful? 0
      , neemuch
      Reviewed on Jun 16, 2018
    • National Insurance Health Insurance
      "Good Service"
      0.5 4.0/5 "Great!"
      I've a health insurance policy from the National Insurance. I am paying the premium of 1400 per year. You can claim this policy at any network hospitals in the country. The need to nofity the customers about the partnered hospitals. If they have tie up with the a new hospital they need to send updates to the customers or publish it on their website.
      Was this review helpful? 0
      , chennai
      Reviewed on Jun 16, 2018
    • Star Health Health Insurance
      "Average Service"
      0.5 2.0/5 "Expected more"
      I'm using the Star Health insurance policy. I do not have any claim experience yet. I pay a premium of 8000 Per year. They don't send any renewal notifications. Their Service is good. The coverage is 1 lac for whole family per year. They need to improve their notifications and keep the customer posted about important dates.
      Was this review helpful? 0
      , chennai
      Reviewed on Jun 16, 2018
    • Royal Sundaram Health Insurance
      "Good Service"
      0.5 3.5/5 "Pretty good"
      I've been using the health insurance policy from Royal Sundaram for a while. I am paying the premium of 8000, many of my friends recommended Royal Sundaram. I never had any claim experience with the policy. Overall it has been a smooth experience. I'll have to wait and see how they respond to my requirement in future.
      Was this review helpful? 0
      , chennai
      Reviewed on Jun 16, 2018
    • Apollo Munich Health Insurance
      "The Best"
      0.5 5.0/5 "Blown Away!"
      Since I'm working with health insurance. It is easy to claim in Apollo Munich. The best hospital list covered in this policy. The best health insurance company in PAN India. In my company, they are paying the insurance premium for me and my family.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Jun 14, 2018
    • HDFC Ergo Health Insurance
      "Good Service"
      0.5 3.5/5 "Pretty good"
      I've a health insurance policy with the HDFC Ergo. I pay a premium of 6100 Per year, I do not have any claim experience with the policy and it offers full coverage for my entire family. They offer a coverage 2 lacs annually which is pretty good for me. Overall it has been a good experience with the features of the policy. .
      Was this review helpful? 0
      , ghaziabad
      Reviewed on Jun 14, 2018
    • Bajaj Allianz Health Insurance
      "Good Health Insurance policy"
      0.5 5.0/5 "Blown Away!"
      So far i have never claim the health insurance. I can claim upto 7 lakhs. I have taken this insurance policy for me and dependent. The employer take care of the premium amount. I have never contact the customer care. Almost most of the hospital has been covered in this health insurance
      Was this review helpful? 0
      , coimbatore
      Reviewed on Jun 14, 2018
    • Universal Sompo Health Insurance
      "Average"
      0.5 3.0/5 "Satisfactory"
      I have a health insurance policy taken from Universal Sompo, it was the best deal I came across when I was looking for the policy, the premium amount that I paid was quite reasonable and not too high, the sum assured amount was also good. I never got chance to take the services of this policy I have no claim experience from them so far.
      Was this review helpful? 0
      , kolkata
      Reviewed on Jun 14, 2018
    • Universal Sompo Health Insurance
      "Best Health insurance policy"
      0.5 5.0/5 "Blown Away!"
      I have taken this policy for the first time. I have not claimed the policy so far. I have paid around for Rs.8500 as premium. It family based health insurance policy. I can claim upto 5 lakhs. Cashless treatment is available. There is no pre-existing offer is available. I have taken this policy last month. Most of the hospitals are covered in this policy.
      Was this review helpful? 0
      , gurgaon
      Reviewed on Jun 14, 2018
    • review Health Insurance
      "Good policy"
      0.5 4.0/5 "Great!"
      It is a health insurance policy from HDFC. Accidental benefits are there. If i admit in a hospital, i can claim for that also. I took this policy for my whole family. I'm paying Rs. 4500 for every year. I can claim upto 3 lakhs in a year. If i renew the policy without any claim, they will offer some bonus points. I never claimed this policy so far. Cashless treatment is available.
      Was this review helpful? 0
      , chennai
      Reviewed on Jun 13, 2018
    • Royal Sundaram Health Insurance
      "Good policy to use"
      0.5 5.0/5 "Blown Away!"
      I got the health insurance policy from the ROYAL SUNDARAM GENERAL INSURANCE company and i have got it around 5 years. This policy covers 4members in my family and it has the medical coverage amount of Rs,3,00,000 . I pay the premium amount of Rs,8,000 to renew the policy every year.
      Was this review helpful? 0
      , bangalore
      Reviewed on Jun 13, 2018
    • United India Health Insurance
      "Good policy to use"
      0.5 5.0/5 "Blown Away!"
      Got the health insurance policy from the UNITED INDIA INSURANCE company and I having this policy from past 5 years. The customer support and the response is good with the United India and this policy covers 4 members in the family. This policy has the medical coverage up to Rs,3,00,000 and I pay the premium amount of Rs,10,900 to renew this policy.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Jun 13, 2018
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