This scenario is for illustration purposes only. It is a fictional claim scenario and does not depict any actual person or claim. For the full write up, including plan details for both the Arch Plan and the Scheduled Indemnity Plan, as well as all claim details, please download Comparison of an Arch Accident Medical Expense Plan vs. A Fixed Accident Scheduled Indemnity Plan.
How does Accident Medical Expense Insurance differ from other types of scheduled indemnity insurance? Read this claims scenario to find out.
The following scenario follows Peter, a 52-year-old dedicated husband and father of three from Georgia. Because of his son’s need for an expensive monthly medication, Peter opted to purchase a $0 deductible major medical plan from his employer. He also purchased a $10,000 Accident Medical Reimbursement plan from Arch. Although Peter’s in-network deductible is $0, the major medical plan he chose has an out-of-network deductible of $1,600, and a responsibility to pay 30% coinsurance toward services rendered by an out-of-network provider. Peter’s total out-of-network family maximum responsibility is $12,000. During the plan year Peter has not incurred any out-of-network expenses that would count toward those out-of-network maximums.
Estimated monthly premium for an arch plan
($10,000 AME/$100 Deductible)
$74.03 (Family Rate)
Estimated monthly premium for the Other plan
(Scheduled Indemnity)
$76.69 (Family Rate)
Peter was excited to help his friend John move into a new log cabin in a remote mountain area. He kissed his family goodbye and set out on a road trip to help his friend. As he and John were unloading boxes, Peter slipped on a loose stone and hit his head, rendering him unconscious.
Given their remote location, John quickly realized that regular emergency services could take a long time to reach them. John used his satellite phone to call for help, and given the severity of the situation, an air ambulance was dispatched. The medical team arrived swiftly and provided first aid. Peter had regained consciousness, but was airlifted to the nearest hospital for further treatment.
Luckily the doctors diagnosed Peter with only a mild concussion, and he was released from the hospital after spending two days under observation. While John, Peter and his family were relieved the injury wasn’t serious, Peter and his wife were shocked at the size of the bill that arrived a few weeks later from the out-of-network hospital where treatment was rendered.
| The Arch Plan | The Other Plan | |
|---|---|---|
| Total Medical Expenses Incurred | $102,062.62 | $102,062.62 |
| Total Major Medical Out-of-Pocket responsibility for Peter, including network deductible and 30% coinsurance | $12,000.00 | $12,000.00 |
| Deductible for the Plan | $100.00 | $0.00 |
| Total paid by the Plan | $10,000.00 | $4,070.00 |
| Peter’s Net Out-of-Pocket costs | $2,000.00 | $7,930.00 |
For full details, please download Comparison of an Arch Accident Medical Expense Plan vs. A Fixed Accident Scheduled Indemnity Plan.
In Summary
After the incident Peter reached his major medical plan’s full annual family out-of-pocket maximum of $12,000. With the Arch Plan, Peter was reimbursed $10,000, which left him with a new out-of-pocket responsibility of $2,000. Under the Other Plan, Peter would have been reimbursed only $4,070 and would have been responsible for the remaining balance of his out-of-pocket expenses of $7,930.
By purchasing the Arch Plan, Peter was able to reduce further his out-of-pocket obligations by more than $5,930 when compared to the Other Plan. Peter paid $2.66 less per month for the Arch Plan than the Other Plan and received a larger reimbursement amount to cover his out-of-pocket expenses than he would have had under the Other Plan.
Policy benefits described herein are supplement health insurance and are NOT a substitute for major medical or other comprehensive health insurance coverages. Policyholders must attest that they, and any other individual for whom they are purchasing coverage, have minimum and essential major medical coverage as required by the Affordable Care Act.