The benefit limit (plafond) is the most the insurer will pay under a cover; the co-payment (copagamento) is the fixed amount you pay each time you use the network; the excess (franquia) is the part of the bill you always pay before the insurer contributes. Understand these three terms and you will understand what a health policy in Portugal will really cost you when you need it. Here they are, with a worked example.

Benefit limit (plafond or capital): the ceiling for each cover

The benefit limit, also called the insured amount (capital seguro), is the maximum the insurer will pay under a cover over a period, usually a year. Even if the bill is higher, the insurer will not pay above that amount.

Each cover has its own limit: consultations, hospital care, childbirth, dental, medicines.
The limit may be per person or shared across the household, depending on the policy.
Some policies have sub-limits within a cover, for example a separate limit for prostheses within hospital cover.
Limits are normally reset at the annual renewal.

The hospital (internamento) limit matters most. That is where the big bills are, and a low figure can be used up by a single operation.

Co-payment: what you pay each time in the network

The co-payment is a fixed amount you pay directly to the doctor, clinic or hospital when you use the insurer’s network (rede convencionada). The insurer pays the rest, within the limit.

It may differ by service: a consultation, blood tests, a scan, a hospital stay.
For hospital stays and childbirth, it may be a higher fixed amount per episode.
Its big advantage is predictability: you know in advance what you will pay.

One trend worth knowing about: a growing number of insurers offer Outpatient cover (consultations, tests and treatment without a hospital stay) with no annual limits, only with co-payments. Some insurers also charge nothing for outpatient consultations and tests when they are carried out in their own clinic networks.

Excess and reimbursement rate: how claiming back works

When you see a doctor outside the network and your policy includes reimbursement (reembolso), two more terms come into play:

Excess (franquia): an amount you always bear, deducted before the insurer works out what to pay back. It may apply per claim, per year or per cover, depending on the policy.
Reimbursement rate (comparticipação): the percentage of the cost the insurer refunds, for example 80% or 90%, after the excess is deducted.

As a rule, policies with higher excesses have lower premiums. It is a trade-off: you pay less each month, but more when you use the cover.

A worked example

Imagine a policy with these terms (figures purely illustrative):

Consultations: €20 co-payment in the network; outside the network, 80% reimbursement up to €1,000 a year.
Hospital care: €50,000 annual limit; outside the network, €500 excess and 90% reimbursement.

Now three situations:

Consultation in the network: you pay €20 at reception. The insurer pays the rest.
Consultation outside the network costing €80: you pay the €80 and claim. You receive 80% of €80, which is €64. You bear €16. You have €936 of consultation cover left that year.
Hospital stay outside the network costing €5,000: first the excess is deducted: €5,000 minus €500 leaves €4,500. The insurer reimburses 90% of that, which is €4,050. You bear €950. You have €45,950 of hospital cover left that year.

Had that stay been in the network, you would have paid only the hospital co-payment set in your policy, usually well below €950.

Network or reimbursement: which pays off?

The example shows a general rule: using the network is usually cheaper and simpler, because you do not pay upfront or wait for a refund. Reimbursement gives you the freedom to see any doctor, which can matter if you already have a trusted specialist outside the network.

When I compare policies for a client, I look at three things: whether the doctors and hospitals they use are in the network, what each service costs in the network and, for anything outside it, the excess and the reimbursement rate. In the Algarve, where private healthcare is concentrated in a handful of towns, checking the network close to home makes a real difference day to day. If you split your time between Portugal and another country, also check what the policy covers abroad.

There are as many options as there are insurers on the market, and each one has several plans, with different limits, co-payments and excesses. The cheapest plan is not always the one that pays off most. Get in touch and I will recommend the best option for your situation.

What happens when the limit runs out

If you use up the limit of a cover within a year, further costs under that cover are yours until renewal. That is why your maternity or hospital limit should be chosen with the worst realistic scenario in mind, not the most likely one.

Portuguese law also offers a useful safeguard: if an illness first appears while the policy is in force and the policy is not renewed, the insurer cannot refuse benefits for that illness for the following two years, provided the risk is not then covered by another policy and up to the unused insured amount. To benefit, you must tell the insurer about the illness within 30 days of the policy ending, unless there is good reason you could not.

Frequently asked questions

Are the limits reset every year?

In most policies, yes, on the annual renewal date. Check the conditions, as some covers have lifetime limits for the duration of the contract.

Does the excess apply in the network too?

It depends on the policy. In the network, co-payments are more common; excesses tend to apply to reimbursement. But some policies have excesses in the network as well.

Is a lower premium with a high excess a good idea?

It can be, if you rarely use your cover and can afford the excess when you need to. If you expect to use it often or value predictability, a slightly higher premium with low co-payments usually pays off.

If you would like, I will go through your policy conditions with you and show you, with real numbers, what you would pay in each situation: request your health insurance review here.

Sources

General information only. It does not replace reading your policy conditions or personalised advice.