Reasonable & Customary Paramedical Pricing
Most insurance companies pay claims based on the reasonable & customary (“R&C”) amount of that service. This means that fair market pricing is employed.
This means that your plan members will be reimbursed only the R&C amount of the claim they submit.
For example, if a plan member decides to go to Elmwood Spa in downtown Toronto, and pay $150 for an hour-long massage, when the claim is submitted, the plan member will be reimbursed the R&C amount, which may be $90 – even if they have a limit of $300/year for massage.
The reason why R&C is used is to prevent practitioners from charging more than is fair to your group benefit plan. You might be aware that many health practitioners have two tiers of pricing: one for those with a plan, and one for those without. What is to stop a practitioner from charging whatever they want to your plan? It is the same philosophy as why OHIP pays doctors a certain fee per service, instead of allowing them to charge whatever they wish.
Here is the schedule which The Co-operators uses for paramedical services: