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Usual and customary charges for medical care

by John

I am in the stage of negotiating the payment of the medical bills and general damages (pain and suffering) portion of the insurance claim.

The claims representative has reduced the bills from the chiropractor, physical therapist and doctor of osteopathy who treated me and told me that their fees and charges were more than the "usual and customary" charges.

Any comments about this. Isn’t the insurance company who represents the client who damaged me, liable for the charges as long as they are not excessive.

How does this work? any suggestions on getting them to pay the actual medical charges instead of the greatly reduced charges which the claims representative is using.
how is the final settlement determined.

I have seen web sites that total up different charges and then multiply by factors of from 1.5 times the bills to up to 10 times the bills to arrive at an estimate as to how much the claim is worth. is there a way to estimate what each claim is worth?

Thank you for this forum.


Hello John,

Yes, they are liable for your damages as long as the are “usual and customary,” perhaps a better term is reasonable and necessary. Please see more about this here.

In your case, it will mean that the insurance company can decrease what you have been treating for to what it is “customary” or the average of what a similar doctor would have charged for similar treating. This is how they avoid from having you go to the most expensive doctor to simply rack up the bills.

Insurance companies are not very good about sharing the data on how they determine the bills are reasonable and/or necessary and if your treatment was indeed needed. For this, you will need a lawyer. Yes, they can do it and it is a well recognized doctrine in personal injury cases.

As far as calculating the pain and suffering, there is no formula. Some sites will try to give you some guidance, but it is only a guide. Some will do 2, some 2.5, some 9 some 15. I really does not matter. You have to come up with a price for your pain and what is the number you will be willing to take for settlement. To learn more about claim evaluation, please see:

Good Luck,

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