International health insurance guide
Reading your cover: deductible, waiting period, cap and exclusion
Four terms appear in almost every benefits table: the deductible, the waiting period, the coverage cap and the exclusion. They determine what is actually covered, and from when. Here is a short sheet for each one: a definition, why it matters, a fictional example and the question to ask the insurer.
The definitions are general: the exact conditions depend on each contract. The examples are fictional, and their amounts are expressed in imaginary “units”, with no currency and no link to a real offer or price.
1. Deductible
In one sentence
The deductible is the share of costs the insured person pays before the contract starts to reimburse.
Why it matters
It determines the real out-of-pocket cost. Depending on the contract, it applies per treatment, per person or per insurance year: two benefits tables that look alike can therefore behave very differently when a claim is paid.
Fictional example, for teaching purposes
A fictional contract sets a deductible of 100 units per consultation. For a consultation billed 400 units, the first 100 units remain payable by the insured person; the contract then applies to the remaining 300 units, according to its reimbursement rate.
The question to ask the insurer
Does the deductible apply per treatment, per person or per insurance year, and which types of care are left out of it?
2. Waiting period
In one sentence
The waiting period is the time after taking out the contract during which some benefits do not yet apply.
Why it matters
Care received during this period is not covered, even though the contract is already in force. The length varies by benefit: maternity, dental, optical or planned hospital stays, for example.
Fictional example, for teaching purposes
A fictional contract sets a waiting period of 3 months for dental care. Care received after 2 months is not covered; the same care received after 4 months is, within the limits of the benefits.
The question to ask the insurer
Which benefits are subject to a waiting period, how long is it, and are there cases where it is reduced or removed?
3. Coverage cap
In one sentence
The coverage cap is the maximum amount the contract reimburses for a type of care, a period or an event.
Why it matters
Above the cap, the remainder is payable by the insured person. Healthcare costs vary widely from one country to another: the level of the cap and how it applies matter as much as the list of benefits.
Fictional example, for teaching purposes
A fictional contract caps hospital stays at 50,000 units per insurance year. For a hospital stay billed 70,000 units, the contract pays at most 50,000 units; the remaining 20,000 units are payable by the insured person.
The question to ask the insurer
Does the cap apply per event, per insurance year or over the whole length of the contract, and for which types of care?
4. Exclusion
In one sentence
An exclusion is a situation, a treatment or a circumstance that the contract does not cover, even if the rest of the benefit applies.
Why it matters
Exclusions are set out in the policy terms, not always in the summary benefits table. That is where you check, for example, medical history, risky sports or certain areas.
Fictional example, for teaching purposes
A fictional contract excludes injuries that occur during a sports competition. An injury that occurs during a competition is not covered, whereas the same injury occurring during a leisure activity falls under the contract’s benefits.
The question to ask the insurer
What is the full list of the contract’s exclusions, and which ones concern my country, my activity or my health situation?
Going further
These four notions apply differently from one contract to another: only the policy terms are binding. To take stock of your situation, describe your project and request a study.
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