1 day ago
Proposed 10% Health Insurance Co-Pay Could Lower Premiums
Insurers are considering a new rule for some health insurance policies.
Under the proposal, a patient would pay 10% of an eligible hospital claim, while the insurer would pay the rest, subject to the policy.
The patient’s share would stop growing once it reached ₹5 lakh for one claim.
The rule is being considered for hospital stays, not outpatient visits such as ordinary doctor appointments.
The 10% is usually based on the amount the policy accepts, not necessarily the whole hospital bill.
Room limits, exclusions, and other policy rules could mean a patient pays more than 10% overall.
Insurers may charge lower premiums, but they have not announced a standard reduction.
Policyholders are advised to check what they could need to pay themselves.
Non-life insurers are considering a 10% co-payment for retail health insurance claims from January 1, 2027.
The policyholder’s share is proposed to be capped at ₹5 lakh per claim, with a 10% share reaching that cap on an admissible claim of ₹50 lakh.
The co-payment would apply to in-patient hospitalisation costs, including cashless and reimbursement claims; outpatient claims are proposed to be excluded.
The share is generally calculated on the admissible claim, not the total hospital bill, and other deductions could increase what the policyholder pays.
No standard premium reduction has been announced, and the proposal would not allow the co-payment to be waived or changed through a rider or endorsement.
- Who
- Non-life insurers are considering the proposal for retail health insurance policyholders.
- What
- A 10% co-payment on eligible in-patient claims, capped at ₹5 lakh per claim.
- Where
- It concerns retail health insurance claims in India.
- When
- The proposal is for implementation from January 1, 2027.
- Why
- The proposal could lower annual premiums, though policyholders would pay part of hospitalisation costs themselves.
Potential benefit
Potential cost
Premiums and hospital expenses
Potential benefit
The proposal could lower annual premiums, though the amount of any reduction is unknown.
Potential cost
Policyholders would need to pay 10% of the admissible in-patient claim, up to the proposed ₹5 lakh cap, and other policy deductions could increase their total costs.
Choosing to opt out
Potential benefit
The proposal is presented as a way to reduce premiums while sharing claim costs.
Potential cost
The co-payment is not expected to be waivable or adjustable through a rider or endorsement, so customers should not assume they can pay more to avoid it.
Key facts
- Proposed start date
- January 1, 2027
- Co-payment rate
- 10% of the admissible claim amount
- Proposed cap
- ₹5 lakh per claim
- Claim amount at which cap is reached
- ₹50 lakh admissible claim at a 10% co-payment
- Claims described as covered
- In-patient hospitalisation claims, whether cashless or reimbursed
- Outpatient claims
- Proposed to remain outside the arrangement
- Premium impact
- No standard reduction has been announced
- Waiver or modification
- The proposal would not allow the co-payment to be waived, reduced, or modified through a rider or endorsement
Quotes
Deepika Reddy
Co-founder and Finance Director at Anvayaa
“It is being considered for retail indemnity health policies, retail-under-group policies, the indemnity portion of combination products, as well as policies coming through migration or portability. Outpatient claims are proposed to remain outside this arrangement.”
livemint.com
“This means the actual out-of-pocket expense can be higher than 10%. Room-rent limits, deductibles, sub-limits, exclusions and other non-payable expenses can all add to the amount finally paid by the policyholder.”
livemint.com
Sources
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