We have already explained what co-payment means and the criteria behind it. This article answers a more direct question: who actually gains and who loses under this system? A balanced analysis, group by group, so you can place yourself correctly and adapt.
First, what problem is co-payment meant to solve?
Health insurance works by pooling: everyone's premiums together pay for the treatment of those who fall ill. When cover is used beyond necessity — being admitted for something that could be treated as an outpatient, for instance — total costs rise and are passed on as higher premiums for everyone. Co-payment asks the person using the cover to share part of the responsibility, so that use aligns with medical necessity and premiums across the system rise more slowly [check the latest information].
Who gains: the majority, who use their cover when they need it
It sounds contradictory but it is true: ordinary policyholders who claim for genuine conditions are the main beneficiaries, in three ways. First, premiums across the system rise more slowly, so the plan you hold stays affordable long term. Second, medical resources — beds, doctors — go more often to those who genuinely need them. Third, those who voluntarily choose a co-payment plan from the outset get a clearly lighter premium, which suits healthy people with other cover behind them, as we recommend in several articles.
Who loses, and how much do they really lose?
Directly: those affected are policyholders whose claims pattern meets the defined criteria — frequent inpatient claims for minor illness, or an unusually high claims ratio relative to the premium — who may have a co-payment applied at renewal. The fair question is whether that is unjust. Some reassuring facts: the criteria generally do not count claims for critical illness or major surgery; assessment is made annually at renewal; and it can be removed once the claims pattern returns to normal. Genuinely seriously ill people are not the target of this mechanism [check the latest information].
Who should be careful: those on the borderline
The group that should read the criteria closely is people who are genuinely ill but often — young children admitted frequently at their age, or someone with a condition requiring periodic hospital visits. Our advice: keep evidence of medical necessity every time (a doctor's certificate stating the indication for admission), use the level of treatment that matches the actual condition, and if a co-payment is applied and it feels unjust, exercise your right to an explanation and to complain to the OIC, as set out in our article on policyholder rights.
How to position yourself in the co-payment era
Three practices. First, use your cover according to medical necessity, not habit or the idea of "claiming enough to be worth the premium", which ends up more expensive. Second, consider a voluntary co-payment plan if your profile suits it — good health, other cover behind you, cash reserves — in exchange for a sustainable premium. Third, look after your health at source, because the person who barely claims at all is the permanent winner under any system.
In short
Co-payment is not a system of villains and victims. It is a realignment of incentives: those who use cover as needed get a more sustainable system, those who use it beyond necessity are asked to share responsibility, and the seriously ill remain covered as before. Understand where you sit, then match your behaviour and your plan structure to it. If you are unsure whether your plan carries this condition or which structure to choose, message us on LINE any time.
This article was inspired by material from the Thai Financial Planners Association (TFPA) and has been entirely rewritten.