“Reasonable and Customary Charges” under Health Insurance
Many Insurers have incorporated a condition of “ Reasonable and Customary Charges” in health insurance policies and the meaning is as under”
“Reasonable and Customary Charges” means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved.
This condition has put the policyholder in the disadvantage position as the TPA is interpreting in such a manner which reduced the claim amount in the policy.
Example; The person has taken a treatment at Apollo or Fortis or Max Hospitals in Delhi but TPA may settle the claim for the amount which are prevailing in the nearby hospitals irrespective of the standard of the hospital.