What is Health Insurance Co-payment? The New 2025 Standard You Must Know
Introduction
In the world of insurance, "stability" is just as important as "protection." We all want our health insurance premiums to remain reasonable as we age, and we want the system to be there for us when we truly need it.
To achieve this long-term stability and combat medical inflation, the Thai Life Assurance Association has introduced a new standard for health insurance policies. Starting March 2025, a specific Co-payment condition will be included in new policies.
For many, the word "Co-payment" (or "Co-pay") can sound confusing or even worrying. Does it mean I always have to pay? Is my coverage disappearing?
At Pansuk Insurance, we want to clear the air. We believe that understanding the rules is the best way to protect your wallet. The new Co-payment isn't a random fee; it is a specific condition triggered by specific behaviors—and if you understand the rules, you can often avoid it entirely.
In this guide, we will use the official data to explain exactly what this new Co-payment is, the 3 Specific Cases that trigger it, and the Real-Life Calculations you need to know to plan your future.
Defining Co-payment: We Are In This Together
Let's start by changing the definition. In legal terms, Co-payment is a clause in an insurance policy where the policyholder agrees to pay a portion of the medical expenses.
But emotionally, let's call it "Teamwork."
Imagine you are building a house. You hire a contractor (the Insurer) to build it.
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Full Coverage (No Co-pay): You tell the contractor, "Do absolutely everything. I don't want to lift a finger." This is expensive because the contractor takes 100% of the responsibility and effort.
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With Co-pay: You tell the contractor, "I will handle the small stuff—like painting the fence or buying the lightbulbs—but you handle the heavy construction." Because you are helping out, the contractor charges you significantly less.
In health insurance, Co-payment works the same way. You say to the insurer: "I will take care of the small, manageable bills. But if something big happens—like a surgery or a major illness—I need you to step in and handle the rest."
By agreeing to be part of the "team," the insurer rewards you with a lower premium. It is a partnership based on trust and shared risk.
What is the New "Co-payment"?
The file defines Co-payment simply as "Paying Together" (Copayment = จ่ายร่วม).
It acts as a mechanism to ensure long-term stability for all policyholders.
- Who does this affect? It applies to new health insurance policies that start coverage from March 2025 onwards.
- Who is safe? If you bought your health insurance rider before March 2025 and keep renewing it continuously, you will not have these Co-payment conditions .
Unlike a voluntary deductible you choose to lower your premium, this Co-payment is a condition based on your claim history. If your claims in one year are frequent and high relative to your premium, you will be required to share the cost (Co-pay) in the next policy year .
The 3 Trigger Cases: When Do You Have to Pay?
The new standard clearly defines 3 Cases where a policyholder must pay a Co-payment in the following year. These triggers depend on Claim Frequency (how often you visit) and Claim Ratio (the cost vs. your premium).
Case 1: Simple Diseases (Minor Illnesses)
This case targets frequent hospital admissions for minor illnesses that usually don't require sleeping at the hospital. You trigger Case 1 if you meet BOTH conditions in a policy year:
- Frequency: You claim for "Simple Diseases" 3 or more times.
- Claim Ratio: The total claim amount is 200% or more of your annual health insurance premium.
The Consequence: You must pay a 30% Co-payment for every IPD treatment in the next policy year.
Case 2: General Diseases
This applies to general sicknesses but excludes Critical Illnesses and Major Surgeries. You trigger Case 2 if you meet BOTH conditions:
- Frequency: You claim for general diseases 3 or more times.
- Claim Ratio: The total claim amount is 400% or more of your annual health insurance premium.
The Consequence: You must pay a 30% Co-payment for every IPD treatment in the next policy year.
Case 3: The Combined Trigger
If your claim history is high enough to trigger BOTH Case 1 AND Case 2: The Consequence: The penalty increases. You must pay a 50% Co-payment for every IPD treatment in the next policy year .
Let's Do the Math: Real Examples from the Policy
To understand "Claim Ratio," let's look at the exact examples provided in the official document.
The Formula for Claim Ratio:
Example A: Case 1 (Simple Diseases)
- Your Policy Premium: 20,000 Baht/year.
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Your Claims (Simple Diseases only):
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1: 10,000 Baht
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2: 15,000 Baht
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3: 20,000 Baht
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- Total Claims: ฿10,000 + 15,000 + 20,000 = 45,000 Baht.
- Frequency: 3 Times.
- Calculation: ฿(45,000 / 20,000) * 100 = 225%.
Result: Since Frequency ≥ 3 and Ratio ≥ 200%, you must pay 30% Co-payment next year.
Example B: Case 2 (General Diseases)
- Your Policy Premium: 20,000 Baht/year.
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Your Claims (Simple Diseases only):
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1: 30,000 Baht
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2: 25,000 Baht
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3: 30,000 Baht
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- Total Claims: ฿30,000 + 25,000 + 30,000 = 85,000 Baht.
- Frequency: 3 Times.
- Calculation: ฿(85,000 / 20,000) * 100 = 425%.
Result: Since Frequency ≥ 3 and Ratio ≥ 400%, you must pay 30% Co-payment next year.
* Claims under Case 1 (Minor Illnesses) and Case 2 (General Illnesses) will require a 50% co-payment of all medical expenses in the following policy year.
Watch Out: What are "Simple Diseases"?
A key part of avoiding Case 1 is knowing what counts as a "Simple Disease." The document defines these as illnesses that are not severe, can often heal on their own, and typically require simple treatments like household medicine .
Official List of Simple Diseases:
- Dizziness
- Fever of unknown origin
- Headache
- Upper Respiratory Tract Infection (URTI)
- Influenza (Flu)
- Allergy
- Muscle Inflammation
- Diarrhea
- Gastritis and GERD (Acid Reflux)
Pansuk Advice: If you have one of these mild conditions, consider visiting the OPD (Out-Patient Department) instead of admitting yourself. OPD claims do not count towards this Co-payment condition.
The Good News: What is NOT Counted?
The new rules are strict on minor illnesses, but they are designed to protect you when it truly matters. Claims for Critical Illnesses and Major Surgeries are NOT counted in the triggers for Co-payment.
Excluded from the Count (You are Safe):
- Major Surgeries: Defined as surgeries requiring general anesthesia or regional anesthesia (spinal/arm/leg block).
- Critical Illnesses: Including Cancer (Invasive & Non-invasive), Acute Heart Attack, Major Stroke, Chronic Kidney Failure, and Major Organ Transplantation.
- Other Serious Conditions: Alzheimer’s, Parkinson’s, Major Burns, Blindness, and Coma.
Even if you are hospitalized 5 times for chemotherapy or heart surgery, these do not count towards the "3 times" frequency rule.
Frequently Asked Questions (FAQ)
Q1: Does this Co-payment apply to OPD (Out-Patient) treatment?
A: No. It does not relate to OPD treatment. It applies only to In-Patient (IPD) treatments.
Q2: If I have to pay Co-payment next year, does it apply to Critical Illnesses too?
A: Yes. If you trigger the condition (e.g., due to frequent minor flu admissions), you must pay the Co-payment (30% or 50%) for ALL treatments in the next year, including Critical Illnesses and Major Surgeries .
- Example: You trigger a 30% Co-pay due to simple diseases. Next year, you have heart surgery costing 300,000 Baht. You must pay 30% (90,000 Baht).
Q3: If I trigger the Co-payment, is it permanent?
A: No. The company reviews it every policy year. If your claims decrease and you no longer meet the trigger conditions, the Co-payment will be removed in the following year.
Q4: If my policy has a Deductible AND I trigger a Co-payment, how do I pay?
A: You must pay the Deductible first. Then, the remaining amount is calculated for the
Co-payment (30% or 50%).
Q5: How will I know if I have to pay?
A: The insurance company will send you a notification letter at least 15 days before your premium due date.
Conclusion: Plan Smart with Pansuk
The new March 2025 standards are a big change, but they are manageable if you plan ahead.
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For Existing Policyholders: Keep renewing your policy! Do not let it lapse, or you might lose your "grandfathered" status.
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For New Buyers: Be mindful of "Simple Diseases." Use OPD for minor issues to keep your IPD record clean.
At Pansuk Insurance, we are here to help you calculate your risk and choose the plan that fits your life. Don't let the new rules catch you by surprise.
Wondering how these rules affect your family's plan? Let us review your policy and explain the math in simple terms.
👉 [Click here to chat with the Pansuk Team] (Honest advice. Clear explanations based on the official 2025 standards.)
Disclaimer: This information is based on the official Co-payment documents from the Thai Life Assurance Association, effective March 2025. Conditions may vary by insurer.
