If the service is listed as an exclusion, your chances for payment are nil. This, of course, significantly increases risk for insurers. To temper this risk, some insurers are excluding high-cost services they previously covered, such as obstetrical care, transplants, speech and growth therapy and AIDS treatments. Reasonable and customary charges. Under most indemnity plans, those covered by the plan share the cost of medical care with the insurance company after meeting a deductible.
Different answers can mean different amounts of money out of policyholders' pockets.
Indemnity plans usually pay 80 percent to 90 percent of reasonable and customary costs with few, if any, limits on the choice of physician or facility. Managed care plans usually have agreements with their affiliated hospitals and medical groups about the amounts they can charge. But if you are treated by a physician or facility unaffiliated with the plan, the plan may pay as little as 50 percent of reasonable and customary costs. This can be important if you or a staff member need to see a specialist outside the plan or need medical care while away from home. Some base these charges on the average fees among hospitals or physicians in a given ZIP code.