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Copay - What Is Copay In Group Health Insurance?

What is copay?

Copay or copayment in a group health insurance plan refers to the percentage of the health insurance claim amount on the medical bills that the policyholder has to pay on their own, while the insurance company settles the rest of the claim amount. 

However, this copayment option is not mandatory. A few group health insurance policy come with mandatory copayment options. While the others have a copayment clause as an option that the policyholder opts for according to their needs.

It is a copayment when two parties share the premium or claim amount. This is done to reduce the financial burden that falls on the employer when buying group health insurance. Insurers quote a lesser premium when there’s a copayment in claims.

Examples of health insurance copay and how copayment works?

Understanding copay in group health insurance for employees gets better with an example.

For instance, let us consider Tia has a group health insurance plan with 20% copay and the sum insured is 5 lakhs. She goes for treatment at a network hospital and the bills add up to Rs. 50,000. In this case, she pays 20% of 50,000 which is Rs.10,000 from her hands. While the insurance company covers the rest of the bill amount, which is Rs.40,000.

In the above scenario, the sum insured is 5 lakhs and the bills have not crossed the sum insured. But still, Tia has to pay the 20% of her bill as her group health insurance plan comes with a copayment clause. This is how copay in health insurance works.

Premium copayment

When the employer buys an insurance policy, he has to pay the premium. However, the employer can choose if the organization has to be fully or ask the employees to pay a percentage. If the employer chooses to opt for copay, then the employees are informed about the percentage they have to pay. It is generally dealt with the CTC of the employees. The percentage is decided by the employer. Copayment is completely up to the employers’ choice to have to not.

Claim copayment

Employers can introduce copayment up to a certain percentage in claims. When employees raise a claim and there is a copay, they have to pay some money as instructed and the remaining is paid by the insurer. For example, if there’s 10% copay, and the claim is Rs 10000, then the employee pays Rs 1000 and the insurer pays Rs 9000.

Copay is completely customizable. It can be put only for certain treatments or only for dependents or only for employees, etc. For example, the company can keep copay only for maternity or only for claims raised by parents on the employees.

Copay, coinsurance and deductible

Copay

Copay is the fixed percentage of the claim amount paid on certain health care services by the policyholders. The insurance company settles the rest of the bill amount.

Deductible

Deductible is the fixed amount the policyholder pays every year even before the health insurance policy begins covering their medical expenses. Deductibles also allow getting lesser premium amounts. For example, if you can have a deductible of Rs 50000 and the sum insured as 7 lakhs. In this case, if an employee raises a claim of 1 lakh, then Rs 50000 is paid by the employee and the remaining is paid by the insurer.

Coinsurance

It is when two insurers come together to insure a single party. Assume, a large conglomerate with high-risk jobs like working in the gas pipeline wants to buy insurance. It is a huge risk for one insurer to cover the company. So two insurers come to an agreement and insure. Here, one insurer covers more than the other.

Advantages and disadvantages of copay

The advantages and disadvantages of copay revolve mostly around the premiums paid.

Advantages of copay

  • By opting for higher copay percentages, you can reduce the premium paid towards the group medical insurance. 
  • With a copay clause in place, the policyholder will pay a part of the bill. This means they will not raise claims for every other medical treatment he/she takes. This leads to an increase in the judicious and honest use of group health insurance policies.

Disadvantages of copay

  • Even though the employer pays a lesser premium, with a copay option, the policyholder will end up paying more towards the medical expenses.
  • By opting for a copay in health insurance, a policyholder will have to think twice about undergoing a costly medical treatment. Why? Because it is evident that without paying a fair percentage of the bill, one cannot put the health insurance policy into proper use.

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