Per-Visit Maximum

A per-visit maximum is the highest dollar amount your insurance plan will reimburse for a single appointment or treatment with a healthcare provider. If the provider charges more than this set amount, you are responsible for paying the difference. This type of limit is most common in extended health plans for paramedical services, such as physiotherapy, chiropractic care, massage therapy, or acupuncture.

How It Works

The limit applies separately to each visit, and reimbursement is typically based on the lower of the provider's fee or the plan's maximum, multiplied by your coinsurance percentage. In many plans the per-visit cap is applied before coinsurance is calculated, so the insurer reimburses a portion of the capped amount rather than a portion of the provider's actual fee. In Canadian group benefits, a per-visit or per-service cap is one of several cost-sharing mechanisms, alongside coinsurance, deductibles, and reasonable and customary limits, that work together with the annual maximum to define how much a plan will actually cover. Canadian individual health and dental plans, such as Canada Life's Freedom to Choose, structure paramedical coverage with a per-visit amount alongside a per-practitioner annual maximum.

Example:

On a Canadian extended health plan, paramedical services like physiotherapy or massage therapy often carry a per-visit maximum. If your plan reimburses up to a set per-visit amount for massage with coinsurance applied, and your therapist charges more than that maximum, the insurer pays its share of the capped amount and you cover the remaining balance out of pocket for that appointment.

What to Watch For:

Each paramedical discipline may have its own per-visit limit, so confirm the maximum before booking an appointment. Some plans apply both a per-visit maximum and an annual maximum, so reaching either cap can stop further reimbursement for the rest of the benefit year.