Per Disability Reset: The Hidden Rule That Affects Your Employee Medical Insurance Claims
- PT
- Nov 17
- 2 min read
Most people think their medical limits reset every year. But there is a lesser-known rule that can change how much a staff member actually receives from a claim.
This rule is the per disability limit reset, and it affects how employee medical insurance works during repeat admissions, complications, or related conditions.
What Is a Per Disability Limit Reset
A per disability limit means the insurer sets a fixed limit for each medical condition. This limit only refreshes when the insurer considers the next admission a “new disability.” If the second admission is related, the plan continues using the same disability bucket. This applies to room and board, surgical fees, ICU days, and other inpatient charges under employee medical insurance.
How It Affects a Claim
The easiest way to understand this is through a real-life example.
Example: First Admission and Second Admission
Scenario
A staff member is admitted for heart attack. Plan benefits:
Per disability limit: 20,000
Room and board: 250 per day
Surgical limit: 8,000
First Admission
Room and board: 5 days × 250 = 1,250
Surgery: 8,000
Other charges: 6,500
Total: 15,750
Remaining limit: 4,250
Three weeks later, the employee is readmitted due to complications. The insurer reviews it and confirms it is related to the first condition.
Second Admission
New bill: 10,000
Remaining limit: 4,250
Shortfall: 5,750
This amount becomes the employee’s personal cost.
This happens often because employees assume everything resets annually. The brochure rarely highlights this structure.
How Companies Can Reduce Confusion
A short staff guide can help everyone understand:
Their room and board ward type
Whether the plan uses annual limit or per disability
What happens if complications occur
How repeated admissions are treated
When limits may be exceeded
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