{"id":5060,"date":"2025-05-06T16:42:36","date_gmt":"2025-05-06T11:12:36","guid":{"rendered":"https:\/\/www.insurancesamadhan.com\/blog\/?p=5060"},"modified":"2025-05-28T11:22:34","modified_gmt":"2025-05-28T05:52:34","slug":"what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause","status":"publish","type":"post","link":"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/","title":{"rendered":"What To Do If The Claim Deduction Is Due To Reasonable And Customary Clause?"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_76 counter-hierarchy ez-toc-counter ez-toc-grey ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">Table of Contents<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#Introduction\" >Introduction<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#Understanding_the_Reasonable_and_Customary_Clause\" >Understanding the Reasonable and Customary Clause<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#Why_Insurers_Apply_This_Clause\" >Why Insurers Apply This Clause<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#Signs_Your_Claim_Was_Reduced_Due_to_R_C_Clause\" >Signs Your Claim Was Reduced Due to R&amp;C Clause<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#What_Can_You_Do_If_Your_Claim_Is_Affected\" >What Can You Do If Your Claim Is Affected?<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#1_Review_Your_Policy_Document\" >1. Review Your Policy Document<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#2_Request_Detailed_Explanation\" >2. Request Detailed Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#3_Gather_Supporting_Documentation\" >3. Gather Supporting Documentation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#4_File_a_Formal_Appeal\" >4. File a Formal Appeal<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#5_Escalate_to_Higher_Authorities\" >5. Escalate to Higher Authorities<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-11\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#How_Insurance_Samadhan_Can_Help_You\" >How Insurance Samadhan Can Help You<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-12\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#Prevention_Tips_for_Future_Claims\" >Prevention Tips for Future Claims<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-13\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/#Final_Thoughts\" >Final Thoughts<\/a><\/li><\/ul><\/nav><\/div>\n<h2><span class=\"ez-toc-section\" id=\"Introduction\"><\/span><strong>Introduction<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Have you ever faced a situation where your health insurance claim was partially paid, leaving you confused and frustrated? If your insurer mentioned something called the &#8220;Reasonable and Customary Clause&#8221; as the reason for the short-settlement of the claim, you&#8217;re not alone. At Insurance Samadhan, we frequently assist policyholders who face this issue. Read on to learn what this clause means and what you can do if your claim has been reduced because of it.<\/span><\/p>\n<p><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone wp-image-5061 size-full\" src=\"https:\/\/www.insurancesamadhan.com\/blog\/wp-content\/uploads\/2025\/05\/blog2-5.jpg\" alt=\"Struggling With Reasonable And Customar Claim Rejection? Get Help Now\" width=\"1920\" height=\"1080\" \/><\/p>\n<h2><span class=\"ez-toc-section\" id=\"Understanding_the_Reasonable_and_Customary_Clause\"><\/span><b>Understanding the Reasonable and Customary Clause<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">The Reasonable and Customary (R&amp;C) Clause is a provision in health insurance policies that allows insurers to limit the <\/span><a href=\"https:\/\/www.insurancesamadhan.com\/health-claim-reimbursement\"><span style=\"font-weight: 400;\">health insurance claim<\/span><\/a><span style=\"font-weight: 400;\"> amount to what they feel are the &#8220;usual&#8221; charges for any particular treatments or procedures in a geographic area. Simply put, if the hospital charges more than what the insurance company believes is the standard rate for that treatment, they may only pay what they consider is the &#8220;reasonable&#8221; amount.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">For example, if a hospital charges \u20b950,000 for a procedure that typically costs \u20b935,000 in your city according to your insurer&#8217;s data, the insurance company might only approve \u20b935,000, leaving you to pay the difference of \u20b915,000.<\/span><\/p>\n<h2><span class=\"ez-toc-section\" id=\"Why_Insurers_Apply_This_Clause\"><\/span><b>Why Insurers Apply This Clause<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Insurance companies implement this clause to:<\/span><\/p>\n<p><b>1. Control costs<\/b><span style=\"font-weight: 400;\">: By limiting reimbursements to standard rates, they prevent overcharging.<br \/>\n<\/span><b>2. Standardise payments<\/b><span style=\"font-weight: 400;\">: It helps them maintain consistency in insurance claim settlements across various hospitals.<br \/>\n<\/span><b>3. Prevent fraud<\/b><span style=\"font-weight: 400;\">: The clause discourages inflated billing practices.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">While these reasons might seem reasonable from an insurer&#8217;s perspective, they can create significant financial strain for policyholders who weren&#8217;t aware of these limitations.<\/span><\/p>\n<h2><span class=\"ez-toc-section\" id=\"Signs_Your_Claim_Was_Reduced_Due_to_R_C_Clause\"><\/span><b>Signs Your Claim Was Reduced Due to R&amp;C Clause<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">You might have encountered this clause in the <\/span><b>claim settlement process in insurance <\/b><span style=\"font-weight: 400;\">if:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">1. Your claim settlement letter mentions terms like &#8220;reasonable and customary charges,&#8221; &#8220;usual and customary,&#8221; or &#8220;UCR limits&#8221;<br \/>\n<\/span><span style=\"font-weight: 400;\">2. The insurer paid less than the actual hospital bill without clear explanation of other deductions<br \/>\n<\/span><span style=\"font-weight: 400;\">3. The deduction amount seems arbitrary and doesn&#8217;t align with specific policy exclusions<\/span><\/p>\n<h2><span class=\"ez-toc-section\" id=\"What_Can_You_Do_If_Your_Claim_Is_Affected\"><\/span><b>What Can You Do If Your Claim Is Affected?<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">At Insurance Samadhan, we recommend taking these steps if your claim has been short-settled due to the R&amp;C clause:<\/span><\/p>\n<h3><span class=\"ez-toc-section\" id=\"1_Review_Your_Policy_Document\"><\/span><b>1. Review Your Policy Document<\/b><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Start by carefully reading your policy document to understand if and how the R&amp;C clause is mentioned. Look for sections that discuss claim settlements, limitations, or exclusions. Understanding your policy terms is your first line of defense. You can also use the \u2018Know Your Policy\u2019 feature of the Polifyx app to understand your policy better.<\/span><\/p>\n<h3><span class=\"ez-toc-section\" id=\"2_Request_Detailed_Explanation\"><\/span><b>2. Request Detailed Explanation<\/b><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Contact your insurance company and request a written explanation of:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">1. The specific R&amp;C rates they applied to your insurance claim<br \/>\n<\/span><span style=\"font-weight: 400;\">2. How these rates were determined<br \/>\n<\/span><span style=\"font-weight: 400;\">3. The geographic area considered for establishing these rates<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Insurers should be able to justify their decision with concrete data rather than vague explanations.<\/span><\/p>\n<h3><span class=\"ez-toc-section\" id=\"3_Gather_Supporting_Documentation\"><\/span><b>3. Gather Supporting Documentation<\/b><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Collect evidence that supports the reasonableness of the charges:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">1. Get a detailed breakup of the hospital bill<br \/>\n<\/span><span style=\"font-weight: 400;\">2. Request a letter from your doctor explaining why the procedure costs were justified<br \/>\n<\/span><span style=\"font-weight: 400;\">3. Obtain information about similar charges from other hospitals in your area<br \/>\n<\/span><span style=\"font-weight: 400;\">4. Ask for the hospital&#8217;s standard rate card for the procedure<\/span><\/p>\n<h3><span class=\"ez-toc-section\" id=\"4_File_a_Formal_Appeal\"><\/span><b>4. File a Formal Appeal<\/b><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Most insurance companies have a formal appeals process. Submit a written appeal that includes:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">1. Your policy number and claim reference<br \/>\n<\/span><span style=\"font-weight: 400;\">2. A clear explanation of why you believe the full amount should be covered<br \/>\n<\/span><span style=\"font-weight: 400;\">3. Supporting documentation from your doctor and hospital<br \/>\n<\/span><span style=\"font-weight: 400;\">4. Reference to any policy language that supports your case<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Be specific about which charges you&#8217;re contesting and why you believe they are reasonable.<\/span><\/p>\n<h3><span class=\"ez-toc-section\" id=\"5_Escalate_to_Higher_Authorities\"><\/span><b>5. Escalate to Higher Authorities<\/b><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p><span style=\"font-weight: 400;\">If your appeal is rejected, don&#8217;t give up. You can escalate the matter to:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">1. The insurance company&#8217;s grievance cell<br \/>\n<\/span><span style=\"font-weight: 400;\">2. The insurance ombudsman in your region<br \/>\n<\/span><span style=\"font-weight: 400;\">3. The Insurance Regulatory and Development Authority of India (IRDAI)<\/span><\/p>\n<h2><span class=\"ez-toc-section\" id=\"How_Insurance_Samadhan_Can_Help_You\"><\/span><b>How Insurance Samadhan Can Help You<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Fighting short-settled health insurance claims can be time-consuming and complex. That&#8217;s where we come in. At Insurance Samadhan, we specialise in providing insurance claim assistance and can help you with:<\/span><\/p>\n<p><b>1. Professional claim review<\/b><span style=\"font-weight: 400;\">: Our experts will analyse your policy document and claim papers to identify any discrepancies or unfair deductions.<br \/>\n<\/span><b>2. Appeal preparation<\/b><span style=\"font-weight: 400;\">: We&#8217;ll help you draft a comprehensive appeal with the right\u00a0 arguments.<br \/>\n<\/span><b>3. Regulatory assistance<\/b><span style=\"font-weight: 400;\">: If needed, we can guide you through the appeals process of approaching regulatory authorities.<\/span><\/p>\n<h2><span class=\"ez-toc-section\" id=\"Prevention_Tips_for_Future_Claims\"><\/span><b>Prevention Tips for Future Claims<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">To avoid R&amp;C clause issues in the future during the <\/span><a href=\"https:\/\/www.insurancesamadhan.com\/blog\/simplifying-the-complexities-of-insurance-claim-settlement-process\/\"><span style=\"font-weight: 400;\">claim settlement process<\/span><\/a><span style=\"font-weight: 400;\"> in insurance:<\/span><\/p>\n<p><b>1. Research hospital costs<\/b><span style=\"font-weight: 400;\">: Before planned procedures, inquire about costs at multiple hospitals.<br \/>\n<\/span><b>2. Consult with your insurer<\/b><span style=\"font-weight: 400;\">: For planned hospitalisations, ask your insurance company about their R&amp;C limits for your treatment.<br \/>\n<\/span><b>3. Choose network hospitals<\/b><span style=\"font-weight: 400;\">: Prefer hospitals that have tie-ups with your insurer, as they generally have pre-agreed rates.<br \/>\n<\/span><b>4. Review your policy<\/b><span style=\"font-weight: 400;\">: During renewal, consider policies with more transparent and generous R&amp;C provisions.<\/span><\/p>\n<h2><span class=\"ez-toc-section\" id=\"Final_Thoughts\"><\/span><b>Final Thoughts<\/b><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><span style=\"font-weight: 400;\">The Reasonable and Customary Clause, while legitimate, should not become a tool for unfair health insurance claim reductions. Understanding your rights and taking appropriate action can significantly improve your chances of receiving fair compensation.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Remember, insurance is meant to provide financial security during medical emergencies. If you believe your claim has been unfairly short-settled due to the R&amp;C clause, don&#8217;t hesitate to challenge it. At Insurance Samadhan, we&#8217;re committed to helping you navigate these complex situations and making sure you receive the coverage you&#8217;re entitled to under your policy.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Don&#8217;t let claim short-settlements add to your stress during already difficult times. Reach out to us, and let our expertise work for you in securing what&#8217;s rightfully yours.<\/span><\/p>\n<p><a href=\"https:\/\/www.insurancesamadhan.com\/register?utm_source=organic&amp;utm_medium=blog&amp;utm_campaign=blog_post&amp;utm_term=blog_term\"><strong>Click here to register your complaint with Insurance Samadhan<\/strong><\/a><\/p>\n<p>Visit our website:\u00a0<a href=\"https:\/\/www.insurancesamadhan.com\/\">insurancesamadhan.com<\/a><\/p>\n<p>Mail us at\u00a0<a href=\"mailto:corporate@insurancesamadhan.com\">corporate@insurancesamadhan.com<\/a><\/p>\n<p><script type=\"application\/ld+json\">\n{\n  \"@context\": \"https:\/\/schema.org\/\",\n  \"@type\": \"Article\",\n  \"mainEntityOfPage\": {\n    \"@type\": \"WebPage\",\n    \"@id\": \"https:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/\"\n  },\n  \"headline\": \"What To Do If The Claim Deduction Is Due To Reasonable And Customary Clause?\n\",\n  \"description\": \"Learn what the Reasonable and Customary Clause in health insurance means and how to handle claim deductions caused by it.\n\",\n  \"image\": {\n    \"@type\": \"ImageObject\",\n    \"url\": \"https:\/\/i0.wp.com\/www.insurancesamadhan.com\/blog\/wp-content\/uploads\/2025\/05\/blog2-5.jpg?resize=640%2C360&ssl=1,\n    \"width\": 1920,\n    \"height\": 1080\n  },\n  \"author\": {\n    \"@type\": \"Person\",\n    \"name\": \"Insurance Samadhan\"\n  },\n  \"publisher\": {\n    \"@type\": \"Organization\",\n    \"name\": \"Insurance Samadhan\",\n    \"logo\": {\n      \"@type\": \"ImageObject\",\n      \"url\": \"https:\/\/insurancesamadhan.com\/images\/logo.svg\",\n      \"width\": 224,\n      \"height\": 47\n    }\n  },\n  \"datePublished\": \"2025-5-06\",\n  \"dateModified\": \"2025-5-06\"\n}\n<\/script><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introduction Have you ever faced a situation where your health insurance claim was partially paid, leaving you confused and frustrated? If your insurer mentioned something called the &#8220;Reasonable and Customary Clause&#8221; as the reason for the short-settlement of the claim,&hellip; <a href=\"http:\/\/www.insurancesamadhan.com\/blog\/what-to-do-if-the-claim-deduction-is-due-to-reasonable-and-customary-clause\/\" class=\"more-link\">Continue Reading <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":14,"featured_media":5062,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_uag_custom_page_level_css":"","footnotes":""},"categories":[358,324,313],"tags":[],"class_list":["post-5060","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-claim-rejection","category-claim-settlement","category-health-insurance-claim"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Struggling With Reasonable And Customar Claim Rejection? 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