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 claim scenario follows Sylvia, a single 49-year-old professional living in New Jersey. Sylvia purchased a high deductible health plan from her employer and a $5,000 Accident Medical Reimbursement plan from Arch. Sylvia has a major medical in-network deductible of $1,600 and at the time of the accident had not yet made any payments for medical expenses in the current plan year that counted toward that deductible.
Estimated monthly premium for an arch plan
($5,000 AME/$100 Deductible)
$12.70 (Single Rate)
Estimated monthly premium for the Other plan
(Scheduled Indemnity)
$30.49 (Single Rate)
On an unusually warm sunny afternoon in January, Sylvia decided to enjoy the weather with a stroll through the local park, her favorite strawberry ice cream in hand. As she roamed, Sylvia noticed her friend, Amy, and Amy’s golden retriever playing fetch in the distance.
The dog, Max, had a weakness for anything sweet, and recognized Sylvia as she came closer. The enticing smell of strawberry ice cream proved too much for the playful dog. In a moment of unrestrained enthusiasm, Max leapt towards Sylvia, aiming for a lick of the delicious treat. Unfortunately, in his eagerness, Max accidentally bit Sylvia’s arm.
Amy was mortified. Max, realizing his mistake, whimpered apologetically. Despite the surprising incident, and a bite injury to her arm, Sylvia couldn’t help but laugh at the comical guilt written all over Max’s face. While she, Amy and Max continue to be great friends and see each other often, but on the day of the incident Sylvia was slightly injured and required medical care. Luckily the incident was right around the corner from an in-network hospital.
Benefit Payment Overivew
| The Arch Plan | The Other Plan | |
|---|---|---|
| Total Medical Expenses Incurred | $1,298.13 | $1,298.13 |
| Total Expenses Paid by Sylvia's Major Medical Plan | $0.00 | $0.00 |
| Deductible for the Plan | $100.00 | $0.00 |
| Total paid by the Plan | $1,198.13 | $305.00 |
| Sylvia's Net Out-of-Pocket costs | $100.00 | $993.13 |
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, Sylvia is now only $301.87 away from reaching her major medical plan’s annual deductible of $1,600. However, with the Arch Plan, she incurred medical expenses of $1,298.13, but only paid $100 out of pocket for the deductible. If Sylvia had purchased the Other Plan, she would have been out of pocket $993.13.
Sylvia was reimbursed $898.13 more from the Arch Plan than she would have been with the Other Plan to pay down on her incurred out-of-pocket expenses.
Furthermore, Sylvia paid $17.79 less per month for the Arch Plan than the Other Plan and came out ahead with a larger reimbursement amount to cover her out-of-pocket expenses incurred as a result of the incident than she 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.
