Tom breaks his wrist: how the math works

For ages under 65

Tom, 60 · fell cleaning his gutters

Tom slips off a ladder and breaks his wrist. Same day: ambulance, ER, X-rays and a cast. Then an orthopedic follow-up and eight physical therapy visits. His accident policy has a $500 deductible, then pays 80% of covered expenses, in addition to his regular health plan.

Covered expenses$6,000

Deductible$500

Policy pays$4,400

What happened

SaturdayThe fall. Ambulance, ER, X-rays, cast. (ER must be within 48 hours.)

Week 2Orthopedic follow-up.

Weeks 3–68 physical therapy visits.

ClaimsCovered expenses total $6,000.

Follow the money

Paid by the policyPaid by the person (or not covered by this policy)Step in the math

Do the math

Covered expenses from the accidentTotal

Ambulance, ER, X-rays, cast, follow-up, therapy

$6,000

Yearly deductibleNot covered

The policy doesn’t pay the first $500

−$500

Amount the 80% applies toThen

$6,000 − $500

$5,500

Policy pays 80%Policy pays

$5,500 × 80%

$4,400

Remaining 20%Not covered

$5,500 × 20%

$1,100

Policy pays$4,400

How the $6,000 in covered expenses splits

$500

$1,100

$4,400

$500 Deductible (not paid by this policy)

$1,100 The 20% (not paid by this policy)

$4,400 Paid by the accident policy

The takeaway

The ER visit has to happen within 48 hours of the accident to count; Tom went the same day. Because the policy pays on top of his health plan, the $4,400 can cover that plan’s deductible and copays for the ER, the cast and therapy.

These are illustrative examples with made-up names. Dollar amounts come from one sample plan design and are shown only to explain how the benefits work. Your actual benefits depend on the plan and options you choose, your state, and the terms, limitations, exclusions and waiting periods in your policy.

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More real-life examples

Linda, 62: 4 days in the hospitalHospital indemnity: see the math Carol, 59: overnight observationHospital indemnity: see the math James, 69: two cleanings and a crownDental & vision: see the math Maria, 66: eye exam and new glassesDental & vision: see the math

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This page is educational and is not an offer of coverage or a recommendation of any specific policy. The policies described are individually underwritten supplemental (indemnity) insurance. They are not major medical coverage, not Medicare Supplement insurance, not long-term care insurance, and not “minimum essential coverage” under the Affordable Care Act. Benefits, benefit amounts, riders, availability and eligibility vary by state and are subject to the terms, limitations, exclusions, waiting periods and pre-existing condition provisions of the actual policy and its outline of coverage. Senior Benefits Hub is an independent insurance agency; licensed since 2013. Not affiliated with or endorsed by any government agency.