Securing health cover for senior citizens is essential due to rising medical inflation. However, senior citizen policies often carry a co-payment clause to make the premium affordable. Many families purchase these policies without explaining this clause to the parent, leading to confusion and financial stress during hospital discharge.
The Cashless Approval and Co-payment surprise
A 68-year-old father was admitted to a network hospital for a knee replacement surgery costing ₹3 Lakhs. The family had a dedicated senior citizen health policy. During admission, cashless service was approved. However, at discharge, the TPA desk informed the family that the insurer's liability was capped at ₹2.1 Lakhs, and the family had to pay ₹90,000 cash before taking the patient home.
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The 30% Co-payment Clause
The family reviewed the policy schedule and discovered a mandatory '30% Co-payment' clause for all treatments. Under this clause, the policyholder must pay 30% of the admissible bill, regardless of the overall sum insured. Additionally, non-medical items (consumables) were excluded from the cover. This case shows why families should compare senior policies for co-payment structures rather than choosing the lowest premium plan.
- Review the co-payment clause in senior citizen health policies before buying or renewing.
- Check if the co-payment is mandatory for all treatments or applies only to specific pre-existing diseases.
- Look for policies that offer 'co-pay waiver' riders by paying a slightly higher annual premium.
- Ensure you maintain emergency liquid cash to handle the co-payment share during hospital discharge.
