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co-pay rules for second insurance

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30 Nov, 2021 by  Playmob Meg

Hi All,

I am in a situation as below.

Total Hospital Expenditure : Rs 4,44,000

1st TPA paid : Rs 3,50,000 (settled)

After that, I made a

claim amount to the 2nd TPA : Rs 94,000 (Where Total sum assured is Rs 3,00,000)

Co-pay charged by 2nd TPA : Rs 44,000 (10% of Total Hospital expenditure)

My question, is the above co-pay charges by 2nd TPA correct.

The total amount claim to the 2nd TPA is only Rs 94,000, which is far below than total sum assured. How the co-pay can be calculated based on Total Hospital Expenditure Rs 4,44,000.

Please help.

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Health Insurance

1 Answer

Regional Director, Amicus Insurance Broking

I assume, you had two policies and the second one had a copay clause. If that is so, please check your policy terms for the copay clause. If it says the copay is applicable on the claim amount on the particular policy, then the deduction is not correct. It should not be on the total claim under both policies.

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