What is Co-pay or Co-payment Insurance?

Insight

4 minutes

26 February 2025

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According to the Life Insurance Association’s document, illnesses and medical conditions that may affect the consideration of Co-payment terms can be summarized into three categories as follows:

1. Simple Diseases

These are mild illnesses that are not serious and do not have a long-term impact on daily life. They are generally easy to treat with over-the-counter medication or may resolve on their own with rest, without the need for medical treatment or hospitalization.

Examples include:
Dizziness, headaches, influenza, allergies, diarrhea, muscle inflammation, gastritis, gastroesophageal reflux disease (GERD), etc.

2. General Illnesses

These refer to medical conditions that may be more severe than simple diseases, but are not classified as critical illnesses and do not require major surgery.

3. Critical Illnesses and Major Surgery

1) Critical Illnesses
Such as advanced-stage cancer, early-stage cancer, myocardial infarction (heart attack), etc.

2) Major Surgery
Surgical procedures that require general anesthesia or regional anesthesia (nerve block).

 

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List of Critical Illnesses
(Source: Thai Life Insurance Association)

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Therefore, under Co-payment conditions, even if the number of claims or the total claim amount is the same, different types of illnesses may result in different Co-payment considerations.

Once the Co-payment condition is triggered in any policy year, in the following policy year the insured will be required to share medical expenses for inpatient treatment (IPD) only, at a rate of 30% or 50% of the IPD medical expenses incurred in that year, based on the following criteria:

Co-payment consideration criteria

1. Simple Diseases

  • Claims made 3 times or more, and

  • Total claim amount reaches 200% or more of the annual premium

Example:
Annual premium: THB 23,000
Claims for illnesses such as influenza, acute diarrhea, etc.
Claims made 3 times or more, with a total claim amount of THB 46,000 or more

2. General Illnesses

  • Claims made 3 times or more, and

  • Total claim amount reaches 400% or more of the annual premium

Example:
Annual premium: THB 23,000
Claims for general illnesses totaling THB 92,000 or more

Co-payment application in the following policy year

  • If either Condition 1 or Condition 2 is met in any policy year, the insured will be required, in the next policy year, to co-pay 30% of inpatient (IPD) medical expenses, regardless of whether the treatment is for critical illnesses, general illnesses, or simple diseases.

  • If both Condition 1 and Condition 2 are met in the same policy year, the insured will be required, in the next policy year, to co-pay 50% of inpatient (IPD) medical expenses, regardless of whether the treatment is for critical illnesses, general illnesses, or simple diseases.

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Co-payment Eligibility Criteria
(Source: Thai Life Insurance Association)

Even if a policy year falls under a 30%–50% Co-payment requirement, if the insured health policy includes outpatient (OPD) coverage, the policy will continue to cover OPD medical expenses at 100%, within the policy limits.

In addition, Co-payment conditions are reviewed annually. They are not permanent. Policyholders with Co-payment health insurance therefore do not need to be overly concerned. In general, it is unlikely that an individual will experience minor or general illnesses three times every year. If, in any year, the insured does not meet the Co-payment criteria, then in the following policy year, the health insurance will return to providing 100% coverage of medical expenses within the policy limits, with no Co-payment requirement for the entire policy year.

Copayment vs. Deductible: What’s the Difference?

Copayment

Copayment refers to cost sharing based on a percentage of medical expenses incurred, such as a 30% Copayment.

  • Higher medical costs → higher shared payment

  • Lower medical costs → lower shared payment

Deductible

A deductible is the initial amount that the insured must always pay first. The insurer is responsible only for expenses exceeding the deductible.

Example:
Deductible of THB 30,000

  • The insured must always pay the first THB 30,000, regardless of total medical costs

  • If medical expenses are less than THB 30,000, the insured pays the full amount

Example 1: 30% Copayment

(Health insurance with no deductible)

  • Medical expenses: THB 100,000

    • Insured pays THB 30,000 (30%)

    • Insurer pays THB 70,000

  • Medical expenses: THB 200,000

    • Insured pays THB 60,000 (30%)

    • Insurer pays THB 140,000

Example 2: 30% Copayment with a Deductible of THB 30,000

Medical expenses: THB 100,000

The insured pays a total of THB 51,000, consisting of:

  1. Deductible: THB 30,000

  2. 30% Copayment on the remaining THB 70,000 = THB 21,000

The insurer pays THB 49,000.

Medical expenses: THB 200,000

The insured pays a total of THB 81,000, consisting of:

  1. Deductible: THB 30,000

  2. 30% Copayment on the remaining THB 170,000 = THB 51,000

The insurer pays THB 119,000.

Medical expenses less than THB 30,000

The insured must pay the full amount, as the expenses do not exceed the deductible.

Source: Thai Life Insurance Association

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