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What is Copay in Health Insurance
Mar 31, 2021

What is Copay in Health Insurance

According to WHO, almost 70% of the Indians spend a huge chunk of their income on healthcare and medicine expenses. These days it is almost impossible for the middle income and the lower-middle-income group to bear the cost of healthcare expenses on their own. This is why it is necessary for people to get health insurance by paying their respective agreed-upon premiums in order to avail financial assistance in case of an accident or any other medical emergencies. It is important to understand what is copay in health insurance in order to opt for the right policy.

What is Copay in Health Insurance?

Nowadays, there are a lot of fraudulent activities related to health insurance. Insurance companies have come up with the concept of Copay in order to dissuade an insured from committing fraud. Copay meaning is simple to explain. Copay is a concept that is agreed upon while signing the insurance contract. The clause states that the insured will have to bear a part or a percentage of the claim amount out of their own pockets and the rest of the claim will be borne by the insurance company. The copay percentage agreed upon by the insured varies from 10-30%.

What is Copay in Health Insurance with example?

Well, now that you know what the concept of the copay is, you might be able to connect with the concept more when you understand what is copay in health insurance with example. For instance, If your insurance policy includes the copay clause of 20 percent and your medical expenses amount to Rs. 15,00,000, you will have to pay Rs. 3,00,000 out of your own pocket and the insurer, i.e., the insurance company will cover the rest of the Rs. 12,00,000.

How does Copay work?

There are two types of claims with any health insurance, namely, cashless health insurance claims and reimbursement for the expenses incurred. In case of a cashless payment option, the insurer will directly settle your expenses with the hospital. Whereas, in case of a reimbursement claim, the insurer will reimburse all the expenses that you incurred while you were undergoing treatment at the hospital. Now there are two situations that will occur when you opt for a copay option. If you opt for a higher copay, you will have to pay a lower rate of insurance premium as compared to opting for a lower copay, where you will have to pay more premium against your policy.

Why do insurance companies have Copay clauses?

Apart from the main reason, which is to save its expenses during claims, there are a lot of reasons due to which insurance companies have copay clauses.
  • To discourage people from unnecessarily going to expensive healthcare centers for their treatments. With copay, the insured will be mindful of their spendings as even they will have to bear a portion of the medical expenses that will occur from these treatments.
  • To dissuade people from making unnecessary claims, such as, dermatologist’s appointments, cold, gastric treatments, etc. Copay insurance dissuades insured from misusing their insurance policy.
  • To prevent fraudulent behavior amongst the insured.

What are the disadvantages of copay? 

While a lot of companies opt for the copay clause, there are a lot of insurance companies who choose to not add a copay clause in the insurance policy because of various reasons.
  • Instances, where the insured has to pay a high copayment amount, may dissuade the insured from seeking proper healthcare attention when they need it, which defeats the entire purpose of buying an insurance policy.
  • While high copayment allows an insured to pay a low premium, the insured will still end up paying more as copayment towards their medical expenses rather than what they’d be saving on the premiums.
People who are well versed with medical insurance products and policies will choose not to buy an insurance policy with the copayment clause as they understand that its disadvantages overpower its advantages.


  • Why do people opt for copay health insurance?
People opt for copay health insurance as they have to pay less premium which makes them cheaper than other insurance policies.
  • Is copayment levied on cashless payment options?
In most cases, copayment clauses are levied only on reimbursement options.
  • Are the policies with copay clauses cheaper than the rest?
Yes, policies with copay clauses are cheaper than the other claim settlement options as the liability divides between the policyholder and the insurance company. This proves to be beneficial for both parties.


Safe to say, now you must have gained some clarity about what copay meaning is! You can now make an informed decision while purchasing a health insurance policy and choose to opt for a copay option knowing all the pros and cons of the concept. *Standard T&C apply Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

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