Role of Deductible and Copay in Health Insurance Policies

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As we all know and understand the benefits of insurance policies. It’s equally important to understand its terms and conditions carefully as well. There are some terminologies as deductible and copay in health insurance, which we’re going to study in detail in this blog. 

Let’s start with definition

Deductible is defined as the initial amount that a policyholder must pay out of pocket before their health insurance coverage kicks in.

The role of deductibles is multifaceted. They serve as a financial barrier, discouraging unnecessary healthcare utilization while encouraging responsible decision-making regarding medical treatments. Higher deductibles often result in lower monthly premiums, making health insurance more affordable for many individuals. However, striking the right balance is crucial, as excessively high deductibles may deter individuals from seeking necessary medical care.

On the other hand, Co-pay is defined as fixed amounts that policyholders pay for specific healthcare services or prescriptions, typically at the time of service. Unlike deductibles, co-pays are a consistent and predictable form of cost-sharing.

The primary purpose of co-payments is to share the financial burden between the insured individual and the insurance provider. These fixed fees contribute to the overall cost of healthcare, ensuring that policyholders have a financial stake in their healthcare decisions. Co-pays also play a role in preventing unnecessary visits to healthcare providers, promoting responsible utilization of medical services.

Suppose your insurance policy has a sum insured of 5 lakhs with a deductible of 1 lakh. This implies that you are responsible for covering the initial expenses up to one lakh, while any expenses exceeding this amount will be covered by the insurance policy.

Whereas, in the case of co-payment, let’s consider a policy with a 20% co-pay on a sum insured of 5 lakhs. This means that every time you make a claim, you are required to bear 20% of the claim amount, and the remaining 80% will be covered by the insurance company. If the claim amount is 1 lac, 20,000 will be paid by insured and 80,000 will be paid by insurance company.

Impact on premium

1. Deductible

The correlation between the deductible and premium is inversely proportional. As the deductible increases, the premium decreases, and conversely, if the deductible is lower, the premium tends to be higher.

Certain individuals may prefer a lower premium, opting to pay more upfront for their healthcare expenses as they arise. While this approach may offer flexibility, it can also introduce unpredictability into one’s expenses, as the timing and magnitude of medical bills remain uncertain.

However, some individuals find comfort in financial security. They appreciate the assurance that when they require their insurance, they won’t need to come up with a substantial amount of money before their plan begins covering costs. Hence, they lean towards a higher premium but a lower deductible, enhancing the predictability of their overall healthcare expenses.

2. Co-payment

Similar to the relationship between deductible and premium, co-pay is also subject to an inverse proportionality with the premium. In essence, a higher co-pay translates to lower premiums for policyholders, whereas a lower co-pay results in higher premiums. When selecting the co-pay amount, policyholders should take into account factors such as their medical history, anticipated expenses, and budget to make an informed decision. 

Insurance Samadhan


In conclusion, understanding the intricacies of deductible and co-pay in health insurance policies is essential for informed decision-making. These terms play a pivotal role in shaping the financial aspects of healthcare coverage. Striking a balance between deductible, co-pay, and premium ensures policyholders can tailor their insurance plans to align with both their healthcare needs and financial preferences. Careful consideration of these factors empowers individuals to navigate the complex landscape of health insurance, fostering a sense of financial security and responsible healthcare utilization.

By- Shivani Modi

Also Read:  Why health insurers do not pay you the full claims amount

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