Glossary
Coverage cap (annual, per benefit)
The maximum amount the insurer reimburses for a given benefit, over a defined period (often a year) or per procedure, beyond which costs remain payable by the policyholder.
A coverage cap can be global (a maximum amount for the whole policy over the year) or set benefit by benefit: hospitalization, routine care, dental, and optical each have their own cap, distinct from the others. A benefits table sets out these amounts line by line.
These per-benefit caps deserve particular attention: a policy advertised as reimbursing 100% of actual costs can nonetheless sharply limit certain benefits (dental and optical in particular), which leaves a significant out-of-pocket balance on that specific care even though the policy appears comprehensive overall.
Example
A policy advertising 100% reimbursement of actual costs can nonetheless cap the dental benefit at a few hundred euros per year, which leaves a significant out-of-pocket balance in the case of costly prosthetic care.
Also searched as: reimbursement cap · annual cap
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