Important Insurance Terms – Medical Maximum

The Medical Maximum is the highest amount your insurance company will pay for covered health services during a plan year. It can apply per illness or injury or per policy term.

• Unlimited Medical Maximum - This refers to a health insurance plan that provides unlimited coverage for certain benefits, meaning there is no cap on the total amount the insurance company will pay for those services while the policy is active.
  

  
  

• Per Policy Term Medical Maximum – This is the total amount the insurance company will pay for all covered medical expenses during the entire policy period (for example, 1 year). It’s the overall cap for everything combined. 👉 Example: If your plan has a $100,000 per policy period Medical Maximum, that means the insurance will only pay up to $100,000 total for all covered medical expenses during your policy period (for example, one year).  

  • You break your arm → hospital and doctor bills cost $25,000 → insurance pays $25,000.

  • Later that year, you need surgery that costs $60,000 → insurance pays $60,000.

  • Now you’ve used $85,000 of your $100,000 maximum.

  • If you get sick again and the bills are $30,000, insurance will only pay $15,000 more (because that’s all you have left of the $100,000 maximum).

  • After you hit the $100,000 limit, you pay the rest out of pocket.

• Per Injury or Illness Medical Maximum – This is the maximum amount the insurance company will pay for each separate injury or illness. If you have multiple injuries or illnesses, each one has its own limit.

👉 Example: If your plan has a $100,000 per injury or illness Medical Maximum

• You break your leg → coverage up to $100,000 for that injury.

• You later get pneumonia → coverage up to $100,000 for that illness.

Questions about your medical maximum? Contact VISIT® Insurance at 703-660-9062 or info@visitinsurance.com and we will be happy to review your policy details with you.