Life & Health Insurance Exam (National Portion)Health InsuranceMedium
A client has a comprehensive major medical policy with a $250 deductible and an 80/20 coinsurance clause, with a maximum out-of-pocket limit of $2,000 (excluding the deductible). If the client incurs $10,000 in covered medical expenses, how much will the insurance company pay?
- A$9,750
- B$8,000
- C$7,750
- D$7,800
Show answer & explanationAnswer & explanation
Correct answer: C. $7,750
First, subtract the deductible from the total expenses. Then, calculate the insured's coinsurance portion. Finally, ensure the insured's out-of-pocket payment does not exceed the maximum limit and subtract that from the total expenses to find the insurer's payment.
Why the other options are wrong
- A. This incorrectly assumes the insurer pays 97.5% of the expenses, without properly applying the deductible or coinsurance.
- B. This incorrectly calculates the insurer's payment as 80% of the total expenses without considering the deductible or out-of-pocket limit.
- D. This is the coinsurance portion of the expenses after the deductible ($10,000 - $250) * 80% = $7,800, but it does not account for the out-of-pocket limit correctly.
Major Medical Expense Calculation
Calculating the insurer's payment in a major medical policy involves applying the deductible, coinsurance percentage, and maximum out-of-pocket limit in sequence to determine the final amount paid by the insurance company.
- Deductible is paid first by the insured.
- Coinsurance applies to the remaining balance after the deductible.
- Maximum out-of-pocket limit caps the insured's total payment (excluding deductible in some cases).
Memory trick: Deduct First, Co-Pay Next, Cap Your Max, Insurer Pays the Rest!