MAXIMUM OUT-OF Clause Samples
The "Maximum Out-Of" clause sets a cap on the total liability or financial exposure that one party may face under a contract. In practice, this clause specifies a maximum dollar amount or percentage that limits how much a party can be required to pay for damages, claims, or losses arising from the agreement. By establishing this upper limit, the clause provides certainty and risk management for the parties, ensuring that potential liabilities are predictable and do not exceed an agreed threshold.
MAXIMUM OUT-OF. POCKET EXPENSE means the total amount you pay each plan year for covered healthcare services. We will pay up to 100% of our allowance for the covered healthcare service for the rest of the plan year once you have met the maximum out-of-pocket expense. See the Summary of Medical Benefits for your maximum out-of-pocket expenses.
MAXIMUM OUT-OF. POCKET EXPENSE means the total amount of coinsurance that you must pay each plan year for certain covered dental care services provided by network dentists. We will pay up to 100% of our allowance for the rest of the plan year once you have met the See the Summary of Benefits for your maximum out-of-pocket expenses.
MAXIMUM OUT-OF. POCKET EXPENSE means the total amount that you must pay each plan year for certain covered health care services. We will pay up to 100% of our allowance for the rest of the plan year once you have met the maximum out-of-pocket expense. • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether a health care service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section 7.0. We review medical necessity on a case-by-case basis. THE FACT THAT YOUR DOCTOR PERFORMED OR PRESCRIBED A PROCEDURE DOES NOT MEAN THAT IT IS MEDICALLY NECESSARY. We determine medical necessity solely for purposes of claims payment under this agreement.
MAXIMUM OUT-OF. POCKET EXPENSE means the total amount you pay each plan year for covered healthcare services. We will pay up to 100% of our allowance for the covered healthcare service for the rest of the plan year once you have met the maximum out-of-pocket expense. See the Summary of Medical Benefits for your maximum out-of-pocket expenses. Copayments for benefits marked with a double asterisk (**) are not applied towards your maximum out-of-pocket expense. After meeting your maximum out-of-pocket expense you will continue to be responsible for these copayments. MEDICALLY NECESSARY (MEDICAL NECESSITY) means that the healthcare services provided to treat your illness or injury, upon review by BCBSRI are: • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether a healthcare service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section