See how much of an admissible claim you pay yourself under a co-pay clause and how much the insurer pays.
A co-pay is a fixed percentage of each admissible claim that you bear yourself. It is common in senior citizen plans, in some standard products, in zone-based pricing (when you are treated in a costlier zone than the one you paid for) and as an optional discount feature.
How to use it. Enter the amount the insurer considers admissible, which is the hospital bill minus non-payable items and any proportionate deduction, and the co-pay percentage from your policy schedule or Customer Information Sheet.
Formula. Your share = admissible amount × co-pay %. Insurer pays = admissible amount − your share, but never more than the sum insured remaining.
Worked example (illustrative). A bill of ₹3,18,000 has ₹18,000 of non-payable items, so ₹3,00,000 is admissible. With a 20% co-pay you pay ₹60,000 and the insurer pays ₹2,40,000. Your total out-of-pocket is ₹60,000 + ₹18,000 = ₹78,000.
Limits. Some policies apply a deductible before the co-pay, some apply co-pay only to certain treatments or to hospitals outside a network, and zone co-pays apply only if you are treated in a higher zone. Read the wording. See the co-pay, deductible and sub-limit guide.
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