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Sr citizen health policy - how does co-pay work along with sub-limits?

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31 May, 2021 by  Clinton Fernandes

I saw that in senior citizen policies, there is co-pay and there are sub-limits on treatments. So how is the final claim settled? Do they first calculate the amount payable under a given treatment and then add co-pay or is co-pay only to expenses without any sub-limits?


Also, could you help with a good senior citizen health insurance that does not pinch the pocket

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31 May, 2021

Hey Clinton,


Sub-limits are applied on the individual expense lines during the period of hospitalization & co-pay is applied on the final bill.


Take the following example - Hospital admission for cataract surgery (usually a daycare treatment)


Hospital Bill - Rs 60,000

Sub-limit on cataract - Rs 50,000

Co-pay in your policy - 20%

Insurer's claim liability - 80% of Rs 50,000 (after application of sub-limit)

Final claim settlement - Rs 40,000


I have taken a very crude example without considering the hospital bill break ups. But, I hope it explains the point.


Best Wishes,


Asad Akbar





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01 Jun, 2021
Sandesh Shetty

As per IRDAI standard policy wording, co-pay is applied on admissible claim amount and the concept of co pay can be explained under below 2 scenarios when the policy states sub limits on any ailment such as Cataract, Hernia, Hysterectomy, etc.


Scenario 1 : When Ailment capping is more than after deducting co pay on admissible amount, then the final claim payable

amount would be the amount which is derived after deducting co pay.

Example : As per policy, Co- pay is 20 %, Cataract sublimit is Rs.50,000/- and total admissible claim amount

(Total Claim amount- Non payable amount) is Rs.60,000/-

Solutions : Step 1 : Apply co pay on admissible amount : 60,000 - (60,000*20%) = Rs.48,000/-

Step 2 : Compare after co pay admissible amount vs Sublimit capping : Rs.48,000/- vs Rs.50,000/-

Step 3 : Final Claim payable amount would be whichever is less i.e Rs.48,000/-




Scenario 1 : When Ailment capping is less than after deducting co pay on Admissible amount, then the final claim payable

amount will not have any impact of co pay and full sublimit capping is payable.

Example : As per policy, Co- pay is 20 %, Cataract sublimit is Rs.50,000/- and total admissible claim amount

(Total Claim amount- Non payable amount) is Rs.70,000/-

Solutions : Step 1 : Apply co pay on admissible amount : 70,000 - (70,000*20%) = Rs.56,000/-

Step 2 : Compare after co pay admissible amount vs Sublimit capping : Rs.56,000/- vs Rs.50,000/-

Step 3 : Final Claim payable amount would be whichever is less i.e Rs.50,000/-



Hope this helps !!!




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01 Jun, 2021
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02 Jun, 2021
Sandesh Shetty
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