What is a reasonable and customary claim limit?

Each insurance carrier has their own unique administrative guidelines, which govern how a carrier processes claims within a plan design. Reasonable and customary (R and C) limits are one example of a common administrative guideline. R and C limits are designed to set a maximum allowable “reasonable” reimbursement amount for health services and major medical items based on various criteria (including submitted claims, provincial and association pricing, manufacturers’ pricing and industry data) – and these limits vary from carrier to carrier.

Where a provider charges more than the R and C limit for a particular service or item, you will need to pay the difference out-of-pocket. The intent here is to protect you from using up large portions of your benefit maximums and, in the case of physiotherapy, massage therapy and so on, allow you to spread those dollars across multiple visits. R and C limits also prevent providers from overcharging for an eligible service or supply and impacting the sustainability of the plan.