Following our article on what copayment is, the next question people want answered is "so when does it apply to me?" This article summarises the framework of conditions used in the assessment, along with how to use your entitlement appropriately.
First: copayment at renewal does not happen to everyone
The copayment mechanism at renewal under the current rules is designed for a group whose claims behaviour meets specific conditions. Most insured people, using their entitlement according to ordinary medical necessity, are unaffected. Understanding the criteria therefore relieves a lot of anxiety.
The framework of conditions
The announced approach looks at claims behaviour in the preceding policy year, primarily at:
- Frequent inpatient claims for simple diseases — hospital admission for symptoms that by medical standards do not require admission. This applies where it occurs more often than the specified number of times and the claims ratio is high relative to the premium.
- A very high overall claims ratio relative to the premium for ordinary illness (excluding critical illness and major surgery), beyond the specified proportion.
The number of occurrences, the claims ratio thresholds, the copayment percentages that may be applied, and the overall cap are the figures in the announcement in force [check the latest information].
Important observations
- Claims for critical illness or major surgery are generally not counted towards these conditions, because the necessity is clear. Seriously ill patients need not worry that major treatment will lead to a copayment.
- The conditions are assessed annually at renewal. If claims behaviour returns to normal the following year, the copayment can be removed under the criteria.
- The company must notify you of the conditions through the proper process; it cannot be applied without notice.
How to use your entitlement appropriately
The simple principle is to match the treatment to the severity. For minor illness such as an ordinary cold, use outpatient treatment or a scheduled appointment rather than asking to be admitted with no medical indication. As well as keeping you clear of the criteria, it helps keep premiums across the whole system from rising quickly.
If a copayment is applied and it seems unfair
You may ask the company for a written explanation of which condition you met and on what claims data. If you believe the assessment is incorrect, you can complain through the OIC's channels, as with any other dispute.
In short
The copayment criteria at renewal are aimed mainly at claims behaviour beyond what is necessary. Use your entitlement according to your actual symptoms, keep complete treatment records, and the chance of meeting the criteria is very low. If you are unsure about your own policy's status, ask the company or get in touch with us.