But I Paid My Premiums! Besides possibly paying the premiums for a medical insurance plan, the insured is almost always responsible for making other, out-of-pocket payments. This practice helps keep overall costs down for both insureds and the insurance companies and ensures that insureds are informed about the costs of health care. For each of the following scenarios, select which type of other cost or provision is illustrated. Jacques has had an illness and an accident during the year. His combined out-of-pocket expense for both incidents was $1,000. The insurance company will now start to pay some of his medical expenses. What does the $1,000 represent? O Internal limits O Coordination of benefits O Participation (co insurance) Deductible Larry's been hospitalized for an illness. His insurance company has started paying 90% of covered medical expenses. What does the 10% of expenses Larry will have to pay out of his pocket represent? Internal limits Coordination of benefits Deductible Participation (co-insurance) Megan has standard, personal medical insurance. After a recent accident, she visited the emergency room. One of the questions on the admission form asked if the accident occurred at work Coordination of benefits Internal limits Participation (co insurance) O Deductible Raphael suffered a profound knee injury, Raphael lives in a remote part of the country and depends on being in excellent physical condition to work Raphael has decided to be extra cautious when having his knee repaired. He is going to a mayor orthopedic hospital 2,000 miles away and having surgery performed by one of the top 10 knee specialists in the country. He already knows that claims for the hospital services and the surgeon will exceed the reasonable and customary charges for his area, Raphael is willing to pay extra for the peace of mind of knowing he received extraordinary care Internal limits Participation (co-insurance) O Coordination of benefits O Deductible Susan, a restaurant owner, is 24 years old and has owned a major medical insurance policy for three years. The policy, which she purchased through her trade association, provides the following coverage: a $3,000,000 lifetime limit a $1,500 deductible and 80% coinsurance clause - Internal limits of $400 per day for a semi-private room and board, $7,500 per occurrence for x-rays, prescription drugs, and other medical expenses, and a $40,000 maximum limit per occurrence on surgical procedures a $25,000 limit per occurrence on rehabilitation and physical therapy . if a hospital charges a room rate that is greater than the policy's stated internal limit, the hospital agrees to reduce the room rate to the policy's internal limit. Last month, Susan was injured during a severe grease file in her restaurant. She spent 3 days in the hospital in a room that cost $600 per day incurred $5,500 for other medical expenses, and 520,000 in surgical expenses Given these claim costs, complete the following table and answer the related questions Total Claim S Policy Limit $400 per day S s S S Hospital charges Surgery costs Other medical costs Rehabilitation and therapy costs Deductible Co Insurance percentage Total cost of claim $ $ $ Based on this data, the total cost to the insurance company is S while the out-of-pocket cost to Susan is How much did Susan save by having her medical insurance policy? S Assume that the hospital changed its payment policy to make the patient responsible for the difference between the hospital's room rate and the insurance company's responsibility (S600 per day versus $400 per day). By how much would Susan's out-of-pocket cost for her hospital room change due in hospital billing? Susan's costs would decrease by $600. O Susan's costs would increase by $360 O Susan's costs would increase by 5600