"Reasonable and customary" means in relation to a charge for medical service, such level which does not exceed the general range of charges being charged by the relevant service providers in the locality where the charge is incurred for similar treatment, services or supplies to individuals with similar conditions, e.g. of the same sex and similar age, for a similar disability, as reasonably determined by the Company in utmost good faith. The reasonable and customary charges shall not in any event exceed the actual charges incurred.

In determining whether a charge is reasonable and customary, we shall make reference to the followings (if applicable):

• treatment or service fee statistics and surveys in the insurance or medical industry;
• internal or industry claim statistics;
• gazette published by the government; and / or
• other pertinent source of reference in the locality where the treatments, services or supplies are provided.

Reasonable & Customary Charges Example:

• If there are two doctors (Dr. A and Dr. B) who will perform the same medical procedure with Dr. A’s charges being within the same level of almost all doctors. However, Dr. B’s charges are significantly higher under the same medical procedures. In this circumstance, unless Dr. B can provide some reasonable proof (such as special expertise), we may otherwise consider Dr. B’s charges as not being ‘Reasonable & Customary’ charges.

• A Doctor’s professional service charge should follow a hospital’s published price list, and the service charge for the same procedures or operation should not differ substantially. Besides, the fee for medical procedure should also not be outside a patients' expectation and budget. Patients can request doctors to explain the charge and rationale for each item.

• How AIA decides what’s Reasonable & Customary?
  AIA will check and refer to the market data objectively to determine reasonable and customary charges, including that of a high-end medical network’s doctor operation fee, private room fee of government hospital, private hospitals’ average medical operation fee and internal data.

• Regarding the charges, we will evaluate and make appropriate adjustment based on various factors, including but limited to qualification, experience of doctors and the complexity of the operation.
  

• However, the final compensation amount will be determined according to the terms of each individual policy document.

Any person with a degree in western medicine and authorised locally to provide medical services. It excludes the following:

a. the doctor is the insured
b. the doctor is the insured’s financial planner, business partner, employer or employee
c. the doctor is a member of the insured’s immediate family

Compensation of reasonable and usual expenses for hospitalisation or treatment given by a registered doctor , a registered or graduate nurse, a physiotherapist, or a chiropractor based on a doctor’s advice and due to an injury caused by an accident within 52 weeks.