(Simple Language + Real Hospital Bill Examples)
Health insurance claim reject nahi hota, BUT कटौती बहुत होती है — aur uska main reason hota hai:
Co-Pay
Deductible
Sub-Limit
99% log policy lete waqt ye 3 terms samajhte hi nahi — isliye claim ke time shock lagta hai.
Chalo ek-ek karke easy language me samajhte hain.
⭐ SECTION 1 — What is Co-Pay?
Understanding co-pay is crucial when navigating health insurance policies.
(Simple Language + Real Hospital Bill Examples)
Health insurance claim reject nahi hota, BUT कटौती बहुत होती है — aur uska main reason hota hai:
Co-Pay
Deductible
Sub-Limit
99% log policy lete waqt ye 3 terms samajhte hi nahi — isliye claim ke time shock lagta hai.
Chalo ek-ek karke easy language me samajhte hain.
❌ Co-Pay ka biggest drawback:
Bill jitna bada, aapka pocket payment utna bada.
Example:
Bill = ₹5,00,000
Co-pay = 20%
You pay = ₹1,00,000
⭐ SECTION 2 — What is Deductible?
Deductible = Aapko pehle ek fixed amount khud pay karna hota hai, uske baad insurance cover start hota hai.
Example:
Deductible = ₹1,00,000
Bill = ₹3,00,000
Insurance pays = ₹2,00,000
You pay = ₹1,00,000
Deductible mainly kahan hota hai?
Super Top-Up Plans
International coverage
Corporate + personal policy combination
High sum-insured plans
✔️ Example 2 – Super Top-Up with Deductible
| Total Bill | Deductible | Insurance Pays |
|---|---|---|
| ₹3,00,000 | ₹1,00,000 | ₹2,00,000 |
⭐ SECTION 3 — What is Sub-Limit?
Sub-Limit = Specific treatments par fixed max cap.
Example:
Cataract: ₹25,000 per eye
Hernia: ₹40,000
Room Rent Limit
Ambulance Limit ₹2,000
Agar bill is limit se upar gaya → excess amount YOU pay.
✔️ Example 3 – Cataract Sub-Limit
Policy Cataract Limit = ₹25,000
Hospital Bill = ₹45,000
Insurance Pays = ₹25,000
You Pay = ₹20,000
📌 Co-Pay vs Deductible vs Sub-Limit (Simple Table)
| Feature | Co-Pay | Deductible | Sub-Limit |
|---|---|---|---|
| Type | Percentage | Fixed Amount | Fixed Cap |
| You Pay | % of every bill | Only once till deductible | Amount above cap |
| Risk | High | Medium | Medium |
| Seen In | Senior plans | Super top-up | Cheap policies |
| Avoid? | YES | Depends | YES |
🔥 SECTION 4 — Real Case Study (With Calculation)
Patient: 60 years old
Bill: ₹2,50,000
Policy Terms:
Co-Pay = 20%
Deductible = ₹50,000
Cataract Sub-Limit = ₹25,000 (assume cataract case)
Step-by-step:
1️⃣ Deductible applies → ₹2,50,000 – ₹50,000 = ₹2,00,000
2️⃣ Sub-Limit applies → Cataract allowed max = ₹25,000
Remaining = ZERO payable beyond this
3️⃣ Co-Pay applies on allowed amount
20% of ₹25,000 = ₹5,000
Final:
Insurance Pays: ₹20,000
You Pay: ₹2,30,000
❗This is why cheap policies are dangerous.
✔️ SECTION 5 — Best Policies Without Co-Pay or Sub-Limits (2025)
Industry data ke hisab se:
Niva Bupa ReAssure 2.0
Care Supreme
ICICI Health AdvantEdge
HDFC Optima Secure
Aditya Birla Activ Health Platinum
इनमे mostly:
No co-pay
No disease cap
No room rent limit
No sub-limits
💡 SECTION 6 — Kaise Check Kare Ki Aapki Policy Me Co-Pay/Sublimit Hai?
Policy documents me ye words dhundo:
“Co-payment applicable”
“Mandatory co-pay for age 60+”
“Deductible of ₹X applicable”
“Disease sub-limit”
“Treatment restriction”
“Room rent capping”
✔️ SECTION 7 — Best Tips (2025)
Always take NO Co-Pay policy
Avoid disease sub-limits
Private room allowed policy lo
Premium thoda zyada sahi hai, claim me lakhon bach jaate hain
❓ FAQs
1. Co-Pay and Deductible same hai?
Nahi — Co-Pay % hota hai, Deductible fixed amount.
2. Kya co-pay senior citizen ko mandatory hota hai?
Old policies me haan, new-age plans me NO.
3. Sub-limits important hai?
NO — ye claim ko restrict karte hain.
4. Kya super top-up me deductible fix hota hai?
Yes — policy start hone ke liye mandatory hota hai.
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