Why, Even With A Health Policy, You End Up Paying

Evaluate the co-payment clause, often buried among the terms & conditions, with care

- Bavadharini KS

Health insurance policies typically cover the entire hospital expenses of policyholders as per policy terms. But, at the time of claim, the settlement paid by the insurer could be lower than your medical bills, leaving you to bear the balance amount.

While the reasons could be plenty for the lower payout, copayment or cost-sharing is a critical clause buried in the policy wordings that needs to be given special attention. Copay could be one of the reasons for lower claim settlement from your health insurer. Here is what you should know about it.

What is it?

Co-payment means a cost-sharing requirement under a health insurance policy that stipulates that the policyholder will bear a specified percentage of the admissible claims amount.

In some health insurance policies, there is a co-pay clause wherein, as a policyholder, you would have to pay a part of the expenses, while the rest would be covered by your insurer. For instance, insurance companies can have a co-pay of 10 per cent on doctor visits or prescription drugs. So, if your total doctor visit expenditure is around ₹2,000, you will have to pay ₹200; the rest will be borne by the insurance company. The copayment clause is meant to discourage people from making ‘unnecessary’ claims.

Insurers including Bajaj Allianz General, Max Bupa Health, Manipal Cigna, Star Health, United India Insurance and Aditya Birla Health have co-pay clauses in some of their policies.

How does it work?