Why do I have an out of pocket expense?

You are likely to have an out of pocket (gap) expense when:

  • The treatment, service or item fee is greater than the maximum item benefit payable as per the policy benefit schedule
  • The sum of benefits claimed for the calendar year to date are in excess of the applicable limit or sub-limit for that service
  • Where a provider performs more than one consultation or identical service on the same day
  • Where a benefit has already been paid for that service by another insurer or where the sum of benefits paid by HIF and other insurers that calendar year has exceeded the applicable sub or annual limit. 
Category: Member Information