This text explains how the co-payment (co-pay) clause works for medical health insurance insurance policies. It originates from an electronic mail trade with a reader about base coverage co-pay limits and tremendous top-up applicability.

This text wouldn’t have been doable however for the skilled steering of  Ajay Pruthi, a fee-only SEBI registered funding advisor. He might be contacted by way of his web site plnr.in.

That is the technical definition of co-payment: “Co-payment is a cost-sharing requirement beneath a medical health insurance coverage that gives that the policyholder/ insured will bear a specified proportion of the admissible declare quantity. A co-payment doesn’t cut back the Sum Insured”.

The admissible declare quantity is the utmost quantity payable beneath the coverage as per the phrases and circumstances, not exceeding the Sum Insured. If the coverage has a deductible, the admissible declare quantity will likely be larger than the deductible.

Contemplate a base coverage of Rs. 5 lakhs with a co-pay of 20%.  Suppose the admissible declare quantity from the hospital invoice is Rs. 1,00,000. We should pay Rs. 20,000 of this quantity, and the insurer can pay Rs. 80,000

If the admissible declare quantity is Rs. 5 lakhs (the utmost quantity doable for this coverage), we should pay Rs. 1 lakh, and the insurer can pay Rs. 4 lakh.

Now think about a hospital invoice of Rs. 7 lakhs (excluding non-medical bills, which no coverage would pay).  Additionally, assume we now have a Tremendous High-Up (STU) coverage for Rs. 10 lakhs with a deductible of Rs. 5 lakhs.

The bottom coverage’s admissible declare quantity right here is Rs. 5 lakhs. So, as above, we should pay Rs. 1 lakh, and the insurer can pay Rs. 4 lakh. On this case, the STU’s admissible declare quantity is Rs. 2 lakhs (7 lakhs minus 5 lakhs deductible). So, the STU can pay Rs. 2 lakhs (no matter how the primary 5 lakhs are paid or if there’s a base coverage).

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