Reasonable and Customary Charges

"Reasonable and Customary Charges" refer to the standard or average fees that healthcare and dental care providers charge for specific services, treatments, or procedures within a particular geographic area. In the context of Dental Care Insurance in Canada, these charges are crucial for determining the maximum amount an insurance company will reimburse for dental services covered under a policy.

Key aspects of reasonable and customary charges in dental care include:

1. Dental Fee Guides: In Canada, each province and territory may publish a Dental Fee Guide, which outlines recommended fees for a wide range of dental services. These guides serve as benchmarks for reasonable and customary charges, helping insurance companies establish reimbursement rates for dental procedures based on the standard practices within the specific region.
2. Geographic Variation: Since the cost of living and the cost of providing dental services can vary significantly across different regions, reasonable and customary charges are often aligned with the local Dental Fee Guide. This ensures that reimbursement rates are fair and reflective of the local dental care market.
3. Reimbursement Limits: Dental insurance plans use the reasonable and customary charges, as guided by provincial or territorial Dental Fee Guides, to set limits on reimbursements. If a dentist's fees exceed these established benchmarks, the policyholder may need to cover the difference, making it important for individuals to be aware of their plan's coverage limits.
4. Provider Fee Structures: While dentists are not required to strictly adhere to the fees suggested in the Dental Fee Guides, many use them as a basis for setting their charges. Policyholders should discuss fees with their dentists to understand how their charges compare to the reasonable and customary rates defined by their insurance plan.
5. Policyholder Awareness: Understanding how reasonable and customary charges are determined, especially in relation to the Dental Fee Guides, can help policyholders make informed decisions about their dental care. It can also aid in anticipating out-of-pocket expenses for dental treatments that exceed the customary rates covered by their insurance.

The concept of reasonable and customary charges, supported by provincial and territorial Dental Fee Guides, plays a vital role in the administration of Dental Care Insurance in Canada. It ensures a standardized approach to determining reimbursement rates, promoting transparency and fairness in the coverage of dental services.