Mark’s heart attack: how the math works

For ages under 65

Mark, 61 · coronary artery disease

Mark has a heart attack, gets a stent, and goes to cardiac rehab. His specified disease policy has a $2,500 yearly deductible, then pays 80% of covered expenses for the conditions on its list. It pays in addition to his regular health plan. His covered expenses come to $20,000.

Covered expenses$20,000

Deductible$2,500

Policy pays$14,000

What happened

Day 1Heart attack. ER and a stent.

Days 2–3In the hospital.

Weeks 2–12Cardiac rehab and follow-ups.

ClaimsCovered expenses total $20,000.

Follow the money

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

Do the math

Covered expensesTotal

Hospital, stent, rehab, follow-ups

$20,000

Yearly deductibleNot covered

The policy doesn’t pay the first $2,500

−$2,500

Amount the 80% applies toThen

$20,000 − $2,500

$17,500

Policy pays 80%Policy pays

$17,500 × 80%

$14,000

Remaining 20%Not covered

$17,500 × 20%

$3,500

Policy pays$14,000

How the $20,000 in covered expenses splits

$2,500

$3,500

$14,000

$2,500 Deductible (not paid by this policy)

$3,500 The 20% (not paid by this policy)

$14,000 Paid by the specified disease policy

The takeaway

Unlike Susan’s lump sum, Mark’s policy pays a share of actual covered costs, for any disease on its list. Because it pays on top of his health plan, the $14,000 can go toward that plan’s deductible, copays, and anything else the heart attack costs him.

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

Susan, 63: first cancer diagnosisCritical illness & cancer: see the math 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

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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.