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NISM Certifications · NISM-Series-X-B: Investment Adviser (Level 2) · Non-Life Insurance Products

Caselet: Meera, 35, a software professional, has a family floater health policy with a sum insured of Rs 10 lakh. Her policy has a 10% co-payment on all claims and no room-rent cap. She is hospitalised and the admissible bill is Rs 3,00,000. How much does the insurer pay, and what does Meera bear?

The insurer pays Rs 2,70,000 and Meera bears Rs 30,000. A 10% co-payment makes the insured share 10% of the admissible bill of Rs 3,00,000, and the insurer pays the other 90%, which lies within the Rs 10 lakh sum insured.

  1. AInsurer pays Rs 2,70,000; Meera bears Rs 30,000Correct
  2. BInsurer pays Rs 3,00,000; Meera bears nil
  3. CInsurer pays Rs 2,00,000; Meera bears Rs 1,00,000
  4. DInsurer pays Rs 2,97,000; Meera bears Rs 3,000

Explanation

Co-payment of 10% means Meera bears 10% of Rs 3,00,000 = Rs 30,000. The insurer pays the remaining 90% = Rs 2,70,000, which is within the sum insured. Paying the full bill ignores the co-payment clause.

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