A recent 8th Circuit case reversed a district court decision that held that the “common and ordinary meaning of out-of-pocket maximum to a reasonable plan participant is the greatest amount that the plan participant will have to pay for medical services per calendar year.” The contract in question, however, made it clear that out-of-network costs beyond the amount specifically provided are not counted against the out-of-pocket maximum, and must be paid by the participant. Reading the contact as a whole, the Court of Appeals found the following language quite persuasive: “You are responsible for Charges that exceed our Out-of-Network Rate for non-participating providers. This could result in You having to pay a significant portion of Your Claim. Balances above the Out-of-Network Rate do NOT apply to Your out-of-pocket maximum.” This language, that the district court found ambiguous, was contained both in the summary of benefits provided by the insurer and also in the evidence of coverage provided to the participant. Unfortunately, the plan participant in this case could have gone to an in-network provider and been required to pay no more than the out-of-pocket maximum of $8,000, but unfortunately paid almost $24,000. Kitterman v. Coventry Health Care of Iowa (8th Cir. 2011).