Copayment ในประกันสุขภาพไทย: สิ่งที่ผู้บริโภคควรรู้

Introduction

The Thai health insurance sector is undergoing a major transformation with the introduction of the Copayment system in new health insurance policies, effective from March 1, 2025. This change is being implemented to address the continuously rising medical costs and to encourage insured individuals to use healthcare services more responsibly.

What is Copayment?

Copayment is a system in which the insured person must share a portion of the medical expenses with the insurance company. This is usually defined as a percentage of the total medical cost, or in some cases, a fixed amount per visit.

Example calculation: If the policy specifies a 30% copayment and the total medical cost is 10,000 THB, the insured person will pay 3,000 THB while the insurance company pays the remaining 7,000 THB.

Conditions for Entering the Copayment System

The Copayment system will take effect when the insured meets one of the specified conditions during the previous policy year. These conditions are divided into three cases, according to the criteria set by the Office of Insurance Commission (OIC) and the Thai Life Assurance Association (TLAA):

กรณีที่ 1: การเจ็บป่วยเล็กน้อยและเคลมบ่อย
- เป็นโรคที่ไม่รุนแรง (เช่น ไข้หวัด ท้องเสีย ปวดหัว)
- มีการเคลมตั้งแต่ 3 ครั้งขึ้นไปต่อปีกรมธรรม์
- อัตราการเคลมมากกว่าหรือเท่ากับ 200% ของเบี้ยประกันสุขภาพที่จ่ายไป
- ผลลัพธ์: ผู้เอาประกันต้องร่วมจ่าย 30% ของค่ารักษาทั้งหมดในปีกรมธรรม์ถัดไป
กรณีที่ 2: การเจ็บป่วยโรคทั่วไปและเคลมสูง
- เป็นโรคทั่วไป (ไม่รวมโรคร้ายแรงตามคำนิยามกรมธรรม์และการผ่าตัดใหญ่ที่ซับซ้อน)
- อัตราการเคลมมากกว่าหรือเท่ากับ 400% ของเบี้ยประกันสุขภาพที่จ่ายไป
- ผลลัพธ์: ผู้เอาประกันต้องร่วมจ่าย 30% ของค่ารักษาทั้งหมดในปีกรมธรรม์ถัดไป
กรณีที่ 3: เข้าเงื่อนไขทั้งกรณีที่ 1 และ 2
- หากผู้เอาประกันเข้าเงื่อนไขทั้งสองกรณีข้างต้น
- ผลลัพธ์: ผู้เอาประกันต้องร่วมจ่าย 50% ของค่ารักษาทั้งหมดในปีกรมธรรม์ถัดไป

Note: If in the following year the claim behavior decreases and no longer meets the above conditions, the insured will no longer be required to make copayments.

Advantages of the Copayment System

Reduced Insurance Premium Burden: Since risk is shared between the insured and the insurance company, policies with copayment tend to have lower premiums than traditional insurance.
Encourages Responsible Use of Services: Having to pay a portion themselves makes the insured consider the necessity of using medical services more carefully, such as avoiding unnecessary hospital visits or choosing services appropriate to their condition.
Creates Sustainability for the Insurance System: Helps reduce the risk of excessive costs for insurance companies, allowing the insurance business to operate sustainably in the long term.
Encourages Health Management: Sharing medical expenses may motivate policyholders to take better care of their health in order to reduce the chances of making insurance claims.

Disadvantages to Be Aware Of:

Increased Financial Burden: Policyholders must have reserved funds to pay their share of medical expenses each time they receive treatment, which can be a burden, especially for those who are frequently ill or have chronic conditions requiring ongoing care.
Uncertainty of Expenses: Although premiums may be lower, the total costs during claims can increase if claim behaviors are not controlled.
May limit access to treatment: Some policyholders may hesitate to seek necessary treatment due to concerns about out-of-pocket expenses.
Not suitable for everyone: This system may not be suitable for individuals with limited income or those with chronic illnesses requiring continuous treatment and frequent claims.

Legal Regulations and Compliance

Office of Insurance Commission (OIC) has issued Registrar's Order No. 23/2566 concerning the specification of types or kinds of health insurance riders, the key terms and conditions in insurance policies, and premium rates for health insurance riders. This order officially incorporates the Copayment system and is effective for all health insurance policies commencing coverage from March 1, 2025 onwards.

Key Points:

Conditions of Copayment do not apply retroactively to health insurance policies purchased and effective before March 1, 2025.
The Thai Life Assurance Association and the Thai General Insurance Association have established clear criteria for Copayment assessment for insurance companies to use as a unified standard.
There have been feedback from consumers and various sectors regarding the impact of the Copayment measure, especially among elderly people and children, who may claim frequently and face higher copayment burdens.

Recommendations for Consumers

To ensure the best coverage and effectively plan finances, consumers should:

Study information thoroughly: Before deciding to purchase health insurance, carefully read the conditions for entering the Copayment system, especially from reliable sources such as the websites of the OIC (oic.or.th) and the Thai Life Assurance Association (tlaa.org).
Assess service usage behavior: Consider whether you or your family members tend to make frequent claims in order to choose a product that suits your needs and budget.
Prepare a financial reserve: If you choose insurance with Copayment, you should have a reserve fund for the out-of-pocket medical expenses to prevent unexpected financial problems.
Consult an expert: If you are unsure, consult a financial advisor or a licensed and trusted insurance agent to get advice suitable for your personal situation.

Summary

The Copayment system is an important adaptation in the Thai health insurance industry, with both advantages and disadvantages. Consumers should deeply understand and carefully consider their personal situations to obtain the best coverage and effectively plan their finances. Although this change presents challenges for consumers, it is a crucial step toward creating a sustainable and fair health insurance system for all parties.