Annual limit, sum insured, out-of-pocket maximum: three caps, one of which you probably don't have

The annual limit — overall plan limit, aggregate limit, annual maximum — is the ceiling on everything the insurer pays for you in one policy year, across every benefit added together. Inside it sit per-benefit limits: outpatient surgical up to a stated figure, chronic conditions up to another, dental up to a third. A per-benefit limit can be reached while the overall limit is barely touched; the overall limit can only be reached by a genuinely large year.

On the plans we arrange the overall plan limit per year is US$1,000,000 at the Major Medical, Standard and Comprehensive levels and US$2,000,000 at Fully Comprehensive; the budget Essential Health plan carries US$100,000. There is no limit on the number of claims — only on the total. Two mechanics follow from that in the wording: every benefit limit is reduced by any coinsurance amount, and exhausting the annual aggregate is a termination trigger for the period of cover. The compare page shows the per-benefit figures at each level.

Sum insured belongs to life and lump-sum products: it is the fixed amount paid out when the insured event happens — on the life plan the insurer offers, the Death Benefit is the sum insured shown on the certificate, with an upfront payment of ten per cent of it on confirmation of eligibility. It is a payout, not a ceiling on reimbursed costs.

In health-insurance conversations the phrase gets borrowed to mean the annual limit, and the borrowing is harmless as long as you know the mechanism is different: health cover reimburses or settles actual costs up to the limit; a sum insured is paid whether or not any cost was incurred. If a quote uses "sum insured" for a health plan, ask which of the two it means.

An out-of-pocket maximum caps what you pay in a year — deductible plus co-payments plus coinsurance — after which the insurer pays everything eligible. It is a construct of US employer and marketplace plans, and Americans moving abroad often assume it travels with them. Generally it does not: international plans define your share as the excess and coinsurance per benefit, per condition, per policy year, and the wording of the plans we arrange states no annual ceiling on that share.

The practical consequence is that the levers you control are the plan level and the coinsurance rate on your certificate, not a cap. Our cost-sharing guide covers those two lines; the deductible guide covers the first one.

Compare the plan levels side by side