Most benefits plans include paramedical services as part of the Extended Health Care benefits. Your paramedical services refer to treatments from health-care providers such as physiotherapists, chiropractors, massage therapists, podiatrists, naturopaths, psychologists, and others.
Review your benefits booklet to find out:
- Which paramedical services you have coverage for
- If a doctor’s note/referral is required (e.g. massage therapist)
- The maximum dollar amount covered for each benefit year
- Your benefit/policy year (e.g. September 1 – August 31, January 1 – December 31)
- Any coinsurance or deductible that you are required to pay towards the cost of the service or item
Paramedical services are subject to reasonable and customary (R&C) limits. These are maximum allowable amounts that an insurer will reimburse on a service or item. This amount reflects the typical cost associated with this service or product in a specific geographical region. While physicians, dentists and hospital services adhere to a provincial fee guide, paramedical service providers can charge whatever they choose for their services and supplies. Therefore, the insurers have established R&C limits to ensure claims are not excessive and to reduce benefits fraud or abuse.
You visit a registered and licensed physiotherapist who charges you $150 for the initial assessment. The reasonable and customary limit for this service in Ontario is $134. When you submit your claim, Manulife, the insurer, will use their R&C limit to determine how much you will be reimbursed. In this case, you will be reimbursed $134, and you would be paying $16 out-of-pocket.
You can find Practitioner R&C by logging into your account and accessing My Claims.
With responsible usage of your paramedical services and smart-consumerism, you will reduce your out-of-pocket expenses and help to reduce benefit plan costs.
Together, we can have a healthier you and a sustainable benefits plan that serves the needs of our members and their families.
Submitting your claim 101
Understanding reasonable and customary limits