Health Insurance Co-Pay of 10%: What the Proposal Means for Your Claim

General insurers have discussed adding a 10% health insurance co-pay to inpatient claims, according to reports published on 5 and 6 October 2026. Mint, citing The Times of India, reported that it would apply from 1 January 2027, with the co-pay capped at ₹5 lakh per claim. Business Standard reported that the General Insurance Council discussed the idea but that an IRDAI approval was unlikely. Neither IRDAI nor the General Insurance Council has issued a circular or public statement on it that we could find.

So for now this is a proposal. It is not a rule, and the two reports differ on how likely it is.

What has been reported so far

Business Standard also noted that many existing products already carry co-pays of 10–30%. These are mostly senior-citizen plans and policies bought with a co-pay in exchange for a lower premium. Products are filed under the use-and-file route, so an insurer would need to change the product wording for any new co-pay to apply.

How a health insurance co-pay would change one claim

Take a family with a ₹10 lakh floater policy. A hospital bill comes to ₹4 lakh, of which ₹20,000 is for items the policy doesn’t pay (consumables, registration, and the like). The admissible claim is ₹3.8 lakh.

Applying the co-pay to the admissible amount, after non-payable items are removed, is our assumption. That is how most existing co-pay clauses work, but the reports don’t say. The reported ₹5 lakh cap would only matter on claims above ₹50 lakh, because 10% of ₹50 lakh is ₹5 lakh. On a ₹15 lakh admissible claim, the co-pay would be ₹1.5 lakh.

A health insurance co-pay is different from the other cost-sharing terms already in many policies. A deductible is a fixed amount you pay before the insurer pays anything. A room-rent cap limits the room category, and claims are often cut proportionately if you choose a costlier room. A disease-wise sub-limit caps what is paid for named treatments, such as cataract. A co-pay is a percentage of every admissible claim, so it grows with the bill. On a ₹15 lakh admissible claim, a 10% co-pay (₹1.5 lakh) costs far more than a typical ₹25,000 deductible would. That is why the reported ₹5 lakh cap matters only at the very top end.

What existing policyholders can rely on

IRDAI’s Master Circular on Health Insurance Business (IRDAI/HLT/CIR/PRO/84/5/2024, 29 May 2024) doesn’t mention co-pays directly. It does set renewal and product rules that limit how a change can reach you.

• Renewal (Chapter I, para 10a): “A health insurance policy shall be renewable provided the product is not withdrawn, except in case of established fraud or non-disclosure or misrepresentation by the Insured.”
• No penalty for past claims (para 10b): “An Insurer shall not deny the renewal on the ground that the policyholder had made a claim (s) in the preceding policy years.”
• No fresh underwriting (para 10c): only when the sum insured goes up, and then “only to the extent of increased sum insured.”
• Withdrawn products (Withdrawal of Products, para 5): existing customers get “a one-time option to renew the existing product, if renewal falls within the 90 days from the date of withdrawal”, or a migration to another product of their choice.
• Multi-year policies (para 6): a product “offered with a term exceeding one year, shall be continued on the agreed terms for all the existing policyholders for the entire policy term.”

Our reading, which is an inference and not a ruling: if insurers bring in a co-pay by changing a product, current terms should run until your next renewal at least, and a multi-year policy should keep its terms to the end of its term. A 2019 IRDAI circular on minor product modifications (IRDA/HLT/CIR/MISC/151/09/2019, para 3.4) said insurers “shall not impose afresh any deductible, co-pay or sub-limits” through such modifications. We couldn’t confirm whether that circular survived the 2024 master circular, which supersedes the circulars listed in its Annexure-6.

From the banker’s desk: people who hold health cover through an employer group policy often don’t know whether their retail top-up has a co-pay already. Read the policy schedule, not the brochure. The co-pay clause is usually in the schedule’s “Special conditions” box.

What you can do this month

1. Check your schedule for any co-pay, room-rent cap or disease-wise sub-limit that already applies.
2. Look at the term. If you renew within the next three months, a two- or three-year policy, where your insurer offers one, locks in the current wording for the full term under para 6. Compare the total premium before you decide.
3. Save for the gap. In the example above, ₹38,000 is the extra amount to set aside if a co-pay ever arrives.
4. If you are porting or migrating, ask the new insurer in writing whether a co-pay applies. Mint’s report says ported and migrated policies would be included.

For context on sizing your cover, see our guides on how much life cover is enough, IRDAI’s distribution rules for policy buyers and NPS Swasthya, a pension-linked health option launched on 1 October.

Still unknown: whether IRDAI will approve, change or reject the idea; whether it would apply to renewals or only to new policies; whether senior-citizen plans that already have a co-pay would get a second one on top; and whether cashless and reimbursement claims would be treated the same. We will update this page if an IRDAI circular appears.

For now, then: nothing has changed on your policy, and the renewal protections in IRDAI’s 2024 master circular are the rules that apply today.

FAQ

Has IRDAI made a 10% co-pay compulsory?

No. As of 11 PM IST on 6 October 2026, we found no IRDAI circular or press release on it. The figure comes from media reports of insurer discussions.

Will my current policy suddenly get a co-pay?

A health insurance co-pay shouldn’t appear mid-term, on our reading of IRDAI’s renewal and product-withdrawal rules. At renewal, a changed product could carry new terms. That is why the wording you receive at renewal matters.

Does a co-pay apply to the full bill?

In most existing policies, it applies to the admissible claim after deductions. The proposal’s exact mechanics haven’t been published.

Where do I complain about a health claim?

First to the insurer’s grievance officer, then through IRDAI’s Bima Bharosa portal. After that, you can go to the Insurance Ombudsman.

Takeaway: treat the 10% co-pay as unconfirmed. Use the next month to read your current policy schedule, because that is what decides your next claim.