Cap on Medical Insurance

[Guest pentex]

Do you have a "lifetime" cap on your medical insurance and if so, how much?

Is your Plan insured, self-insured or a combination of both?

[mroberts]

Most plans that utilize a network (HMO, POS or In-Network for a PPO) usually have an unlimited medical benefit or some high number like $5,000,000. I've also seen plans that have a $1,000,000 limit as well. I believe this is going to vary somewhat by region.

As far as your second question, I'm a consultant, so I can advise you based on your population what you should have. Let me know if you would like to discuss further.

[Sandra Pearce]

We operate a self-insured health plan for approximately 1,300 employees. Our lifetime maximum is $1,000,000. In the eight years the plan has operated we have never had anyone come close to the maximum.

[Larry M]

It is rare that claims will exceed a 1,000,000 or, rarer still, 2,000,000. However they do occur.

The basic question is whether you want your plan to provide a higher maximum (and incur the costs - directly or through reinsurance).

And the related questions:

What would happen to the particular individual whose claim exceeded the maximum you impose? Would providers (hospital, physicians, etc.) stop giving care? Would the individual be forced to use some of his/her savings? Would the individual become eligible for governmental assistance? Would your company advance the money? Would additional care suddenly become unnecessary?