Q. Is a co-payment mandatory in health insurance for senior citizens?

Ans: No. Co-payment is not mandatory in all senior citizen health insurance plans. However, many policies include a co-payment clause due to higher age-related health risks. Some insurers offer plans with low or no co-payment, usually at a higher premium.

Q. What does a 15% co-payment in a senior citizen health policy mean?

Ans: A 15% co-payment means that the insured person must pay 15% of the approved claim amount from their own pocket, while the insurance company covers the remaining 85% of the claim.

Q. Is co-payment in senior citizen health insurance beneficial?

Ans: Co-payment can help reduce premium costs, but it also increases out-of-pocket expenses during claim settlement. Senior citizens who want greater financial protection may prefer plans with lower or no co-payment requirements, while those with sufficient savings may consider plans with a co-payment clause.

Q. How does co-payment work in senior citizen health insurance?

Ans: Co-payment is a fixed percentage of the admissible claim amount that the policyholder must pay during each claim. The remaining portion of the claim is paid by the insurance company as per the policy terms and conditions.

Q. Who is responsible for paying the co-payment amount?

Ans: The insured person or policyholder is responsible for paying the co-payment amount. This share of the claim must be paid out of pocket at the time of claim settlement.

Q. Can I remove the co-payment clause from a senior citizen health insurance policy?

Ans: Some insurers offer optional benefits or add-ons that can reduce or eliminate the co-payment requirement. However, opting for such features generally results in a higher premium.

Q. Does co-payment apply to cashless claims as well?

Ans: Yes. If your senior citizen health insurance policy includes a co-payment clause, it applies to both cashless and reimbursement claims. You must pay the applicable co-payment amount even when availing cashless treatment.

What is Co-Payment in Senior Citizen Health Insurance?

How Does Co-payment Affect Claims for Senior Citizens?

A co-payment clause in your senior citizen policy means that you have to pay a certain portion of the hospital bill from your own pocket.

A higher co-payment percentage means that a lower amount is covered by the insurer. This implies higher out-of-pocket expenses, causing a financial strain at the time of hospitalization. Co-payment can apply to the overall policy or to a specific coverage.

If co-pay applies to the overall policy - You will have to pay a portion from your pocket at every claim.
If co-pay applies to a specific coverage/benefit- You will have to incur out-of-pocket payments for every approved claim associated with that particular coverage or benefit.

Hence, it is important that you compare different senior citizen mediclaim policies to evaluate their co-payment clauses and assess your overall financial risk.

Let us understand how co-payments affect claims through examples:

Scenario 1

Suppose the hospital bill for your knee replacement surgery is ₹4 lakh and your senior citizen plan has a co-pay of 30%.

At the time of claim payment, this shall be calculated as:

Total Hospital Bill ₹4 lakh

Co-payment 30%

Amount Paid by You ₹1,20,000

Amount Covered by Insurer ₹2,80,000

This means that the health insurance company is liable only for a claim payout of ₹2,80,000. You will have to incur 30% of the total bill (₹1,20,000) from your own pocket.
Scenario 2

You are from a Tier-2 city, but you got your treatment at a hospital in a Tier-1 city. The hospital bill amounts to ₹6 lakh. However, your policy mandates a 15% co-payment for treatment at a higher zone hospital.

Now, this means:
- Total Hospital Bill: ₹5 lakh
- Co-payment Clause: 15%
- Required Out-of-Pocket Payment: ₹75,000
Hence, in a situation where you thought all your medical expenses would be covered by the insurer, you will have to immediately pay ₹75,000 because of co-payment.

Most Common Co-payment Scenarios for Senior Citizens

Some of the common situations where you can face co-payment clauses are:

Scenario where co-pay can be applicable	Example
For reaching a specific age	Mandatory co-payment when you reach 65 years
For a specific treatment or medical procedure	Co-payment of 10% on robotic surgery or gallbladder stone surgery
For treatment at non-network hospitals	Getting treatment at a nearby hospital which is not covered in the insurer’s hospital network list
For treatment at higher Zone hospital than applicable to your policy	If you are from tier-2 and getting treatment at tier-1 hospital
For PED treatment	If you have kidney problems and need medical treatment for it
For special doctor visits	Specialist doctor consultations, like with a cardiologist or speech therapist

Disclaimer: The above examples are indicative and only for explanation purposes. Always read the policy wording to check the applicable co-payment clauses.

Why Does Co-payment Exist in Senior Citizen Health Insurance Policy?

Health insurance for senior citizens often has a mandatory co-payment. This is because senior citizens:

Are at a higher health risk
May require frequent doctor visits
Are at a higher risk of hospitalization due to minor injury or illness

This means that senior citizens are more likely to file a claim. This, in turn, increases the risk for the insurer. Insurers levy a co-payment to manage costs and offer coverage at manageable premiums.

Should Senior Citizens Choose a Policy with Co-payment?

For senior citizens, a mediclaim policy with no or low co-payment percentage is often preferable.

If you choose a senior citizen health policy with a higher co-payment (that may have a lower premium), you will have to pay more out of pocket at the time of claims. Considering that the healthcare needs of senior citizens are constantly rising and so are their medical expenses, a higher co-pay means greater financial burden on every claim.

The decision of whether your senior citizen health insurance policy should have a co-payment or not depends on your requirements and financial risk capacity.

When NOT to Choose Policy with Co-payment	When you Can Choose Policy with Co-payment
If you want maximum claim payout	If lower premiums are a priority
If you require frequent hospitalization	If you do not require frequent hospitalization
If you do not want to incur out-of-pocket payments	If you have sufficient savings to bear out-of-pocket expenses with every claim

So, if you have the option to choose a plan where the insurer bears all the expenses, without requiring you to pay a portion of the medical bills, it can be beneficial to maximize the claim amount you receive.

Frequently Asked Questions (FAQs)

Q. Is a co-payment mandatory in health insurance for senior citizens?

Ans: No. Co-payment is not mandatory in all senior citizen health insurance plans. However, many policies include a co-payment clause due to higher age-related health risks. Some insurers offer plans with low or no co-payment, usually at a higher premium.
Q. What does a 15% co-payment in a senior citizen health policy mean?

Ans: A 15% co-payment means that the insured person must pay 15% of the approved claim amount from their own pocket, while the insurance company covers the remaining 85% of the claim.
Q. Is co-payment in senior citizen health insurance beneficial?

Ans: Co-payment can help reduce premium costs, but it also increases out-of-pocket expenses during claim settlement. Senior citizens who want greater financial protection may prefer plans with lower or no co-payment requirements, while those with sufficient savings may consider plans with a co-payment clause.
Q. How does co-payment work in senior citizen health insurance?

Ans: Co-payment is a fixed percentage of the admissible claim amount that the policyholder must pay during each claim. The remaining portion of the claim is paid by the insurance company as per the policy terms and conditions.
Q. Who is responsible for paying the co-payment amount?

Ans: The insured person or policyholder is responsible for paying the co-payment amount. This share of the claim must be paid out of pocket at the time of claim settlement.
Q. Can I remove the co-payment clause from a senior citizen health insurance policy?

Ans: Some insurers offer optional benefits or add-ons that can reduce or eliminate the co-payment requirement. However, opting for such features generally results in a higher premium.
Q. Does co-payment apply to cashless claims as well?

Ans: Yes. If your senior citizen health insurance policy includes a co-payment clause, it applies to both cashless and reimbursement claims. You must pay the applicable co-payment amount even when availing cashless treatment.

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Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in

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*We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30- minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881.

*Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. Policybazaar does not provide any medical or surgical advice or diagnosis and is not responsible for your interactions / treatment by a medical practitioner/hospital. Please consult a registered medical practitioner for any medical or surgical advice. The Information that you obtain or receive from Policybazaar, and its employees, or otherwise on the Website is for informational purposes only. As per the Insurance guidelines, you are allowed to cancel the policy with-in 30 days from the date of Issuance of policy.This option is available incase of policies with a term of one year or more.

*All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.

**All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws.

*₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.

*₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

*₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

*₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

*₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases

*₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.

*₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.

*No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.

*The values taken for effective cost calculation are indicative values and may change as per the selected plan.

*Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.

*Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.

*The scope of coverage may vary from plan to plan.

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