Insurance Claim Estimate Calculator

Work out insurance claim estimate instantly with clear inputs, formula shown and shareable results.

About Insurance Claim Estimate Calculator

Works out the insurer's payment after the deductible and coinsurance, then caps your share at the remaining out-of-pocket maximum.

Formula

Claim settlement

Patient share = min(deductible + coinsurance x (allowed amount - deductible), out-of-pocket maximum remaining); reimbursement = allowed amount - patient share

Worked example

With the default values below, Insurance Claim Estimate Calculator returns Expected insurer reimbursement of $5,200.00. Change any input above and every figure here is recalculated in your browser.

Inputs used

Allowed claim amountaccepts 1–1,000,000: 8,000
Deductible remainingaccepts 0–50,000: 1,500
Coinsurance shareaccepts 0–100: 20
Out-of-pocket maximum remainingaccepts 0–100,000: 6,000

Results

Expected insurer reimbursement: $5,200.00
Your share: $2,800.00
Share before the out-of-pocket cap: $2,800.00
Cap status: Out-of-pocket maximum not reached

Step by step

1Values used
2Claim settlement
3Expected insurer reimbursement= 5,200.00
4Your share= 2,800.00
5Share before the out-of-pocket cap= 2,800.00
6Cap status= Out-of-pocket maximum not reached

Assumptions and limits

The result is derived only from the 4 inputs listed above. Anything not among them is not part of the calculation.
In particular, this calculator does not take inflation, fees or charges or compounding frequency into account.
Figures are rounded for display to 2 decimal places, so totals built from several rounded parts can differ slightly from the unrounded arithmetic.
Educational estimate only. Not a substitute for professional clinical judgement, and must not be used to make treatment or dosing decisions.
This is an estimate for general information and not professional medical advice. See the full disclaimer for the limits that apply to this kind of calculator.

How these calculators are built and tested is described on the Methodology page. If a figure looks wrong, please report it.

Educational estimate only. Not a substitute for professional clinical judgement, and must not be used to make treatment or dosing decisions.

Frequently Asked Questions

What is the allowed amount?

The contracted price between insurer and provider, which is usually well below the billed charge.

Do copays count toward the maximum?

In most plans yes, but premiums never do.