Under most major medical expense policies, allowable expenses are subject to expense participation, or cost-sharing requirements that are designed to encourage insureds to control the amount of their medical expenses. The two most common forms of expense participation requirements are deductibles and coinsurance, and most major medical expense policies include both a deductible and a coinsurance feature.
A deductible is usually a flat dollar amount of eligible medical expenses, such as $200 or $500, that the insured must pay before the insurer begins making any benefit payments under a medical expense insurance policy. Most major medical expense policies contain a calendar-year deductible, which is a deductible that applies to the total of all allowable expenses an insured incurs during a given calendar year. In other words, an insured is required to pay the deductible specified in the policy each calendar year which he submits claims.
Example. Elizabeth Cater is covered by a comprehensive major medical expense policy that specifies a $500 calendar-year deductible. During 2009, Elizabeth incurred a total of $400 in allowable expenses. In 2010 she incurred a total of $800 in allowable expenses