Premium Factors, Cover Features and 2026 Rules
Co-pay, deductible and sub-limits in health insurance: what you pay yourself
How co-pay, zone co-pay, deductibles and disease-wise sub-limits work in Indian health policies, the order they are applied in, and worked claim examples.
Three clauses decide how much of an admissible claim stays with you. A co-pay is a percentage of each claim you bear (for example 10% or 20%). A deductible is a fixed rupee amount you pay before the policy pays anything (for example the first ₹25,000 of a claim or of the policy year). A sub-limit caps what the policy pays for a named treatment or item (for example cataract surgery up to a set amount per eye) whatever the sum insured. Each one lowers the premium, and each one is fine if you understand it and can fund your share. They become a problem when people discover them only at discharge.
This guide belongs to the overview of how health insurance works in India. Use the co-pay calculator to test your own numbers.
The three clauses side by side
| Clause | How it works | Where you usually find it | Effect on a ₹2,00,000 admissible claim (illustrative) |
|---|---|---|---|
| Co-pay 20% | You pay 20% of every admissible claim | Senior citizen plans, some standard products, optional discount, zone mismatch | You pay ₹40,000 |
| Deductible ₹50,000 (per year) | You pay the first ₹50,000 of claims in the policy year | Super top-ups, some low-premium plans, optional discount | You pay ₹50,000 |
| Sub-limit (e.g. ₹40,000 for a procedure) | Policy pays up to the cap for that procedure | Cataract, joint replacement, hernia, modern treatments in some wordings | You pay anything above the cap |
Types of co-pay to look for
Flat co-pay. Applies to every claim. Common in policies sold to people over 60 and in some budget products. IRDAI's standard product, Arogya Sanjeevani, has a co-pay built in; check the current rate in its wording.
Zone-based co-pay. Many insurers divide India into price zones. If you buy a policy priced for a lower-cost zone and are treated in a higher-cost city, the policy may apply a co-pay, commonly 10–20%, to that claim. If you live in a smaller city but would travel to a metro for major treatment, compare the premium for the higher zone against that co-pay.
Voluntary co-pay. You opt into a co-pay in exchange for a discount. Worth it only if the discount is large compared with your expected share.
Non-network co-pay. Some policies apply a co-pay if you use a hospital outside the insurer's network, or a "preferred provider" network.
The order in which deductions are applied
Policies differ, but a typical settlement is worked out in this order:
- Start with the hospital bill.
- Remove non-payable items (gloves, masks, admission kit and others listed in the policy's annexure).
- Apply room-rent proportionate deduction, if any; see room-rent limits.
- Apply sub-limits on named treatments.
- Subtract any deductible.
- Apply the co-pay percentage to what remains.
- Cap the result at the remaining sum insured.
The order matters. A co-pay applied after a deductible gives a smaller rupee share than a co-pay applied first.
Worked example: a senior citizen's knee replacement
Illustrative. A 67-year-old has a ₹5,00,000 policy with a 20% co-pay and a sub-limit of ₹2,00,000 per knee for joint replacement. The bill for one knee is ₹3,40,000, including ₹14,000 of non-payable items. The room is within the policy limit.
| Step | Amount |
|---|---|
| Hospital bill | ₹3,40,000 |
| Less non-payables | − ₹14,000 → ₹3,26,000 |
| Apply sub-limit for joint replacement | capped at ₹2,00,000 |
| Co-pay 20% | − ₹40,000 |
| Insurer pays | ₹1,60,000 |
| Patient pays | ₹1,80,000 |
The patient bears more than half the bill on a policy with a ₹5 lakh sum insured. Without the sub-limit, the insurer would pay 80% of ₹3,26,000 = ₹2,60,800. For people who know a joint replacement or cataract surgery is likely in the next few years, the sub-limit and co-pay matter more than the headline sum insured. This is a reason to read the wording before buying, not a medical judgement on whether the treatment is needed.
Worked example: a deductible plan
Illustrative. A 30-year-old buys a ₹10 lakh plan with a ₹25,000 aggregate deductible for a lower premium. In the policy year she has two claims: ₹18,000 and ₹1,20,000 (admissible amounts).
- First claim: ₹18,000 is below the deductible; she pays all of it. Deductible remaining: ₹7,000.
- Second claim: she pays ₹7,000; the insurer pays ₹1,13,000.
- Total she paid: ₹25,000. Insurer paid ₹1,13,000.
If the deductible were per claim instead of per year, she would have paid ₹18,000 + ₹25,000 = ₹43,000. Always check whether a deductible is per claim or aggregate. Super top-ups work on the same aggregate idea; see the super top-up maths.
Sub-limits that commonly appear
- Cataract surgery, per eye
- Joint replacement, per joint
- Named "modern treatments" such as robotic surgery, some oral chemotherapy or immunotherapy (IRDAI requires these to be covered in policies, but insurers may set limits disclosed in the wording)
- Ambulance charges, per hospitalisation
- AYUSH (Ayurveda, Yoga, Unani, Siddha, Homoeopathy) in-patient treatment in some wordings; IRDAI requires insurers to offer products covering AYUSH, but limits vary by policy
- Maternity, as a fixed amount for normal and caesarean delivery
Checklist before accepting a co-pay or deductible
- Could you pay 20% of a ₹10 lakh claim (₹2 lakh) at short notice?
- Is the co-pay on every claim, or only on certain hospitals, zones or ages?
- Is the deductible per claim or per policy year? Per person or for the whole floater?
- Which sub-limits apply to treatments your family is likely to need?
- Does the premium saving over 5 years exceed your share of one realistic claim?
Compare quotes with these shares included using the quote comparison tool. For the rules on when cover starts for existing conditions, see waiting periods.
Frequently asked questions
Can I remove the co-pay at renewal?
Some insurers offer a co-pay waiver add-on or a variant without co-pay, sometimes after underwriting. Seniors may find that the no-co-pay option costs much more.
Is the co-pay charged on the whole bill or only the admissible part?
On the admissible amount, after non-payables and other deductions. That is why the calculator asks for the admissible amount.
Do sub-limits apply in cashless claims?
Yes. The hospital will collect the excess from you at discharge. The pre-authorisation letter usually shows the limit applied.
Sources and where to check
- IRDAI — master circular on health insurance products, Arogya Sanjeevani standard product
- Bima Bharosa — complaints about deductions not stated in the wording
- Council for Insurance Ombudsmen — disputes about how a clause was applied
