The ‘Reasonably Necessary’ Proof Requirement
To most insurance adjusters, “reasonably necessary” means “cheapest possible.” Likewise, most Claims Examiners, who are basically semi-independent adjusters, don’t consider anything other than the cost when they approve or deny medical bill payment. Cost is one component of the reasonably necessary requirement. But, it’s only one component.
At Administrative Law Judge appeal hearings, a Tampa workers’ compensation lawyer often emphasizes the other two components of the reasonably necessary requirement. This approach helps ensure that job injury victims get the treatment they need, as opposed to the cheapest treatment. Attorneys also help ensure that victims aren’t financially responsible for any unpaid costs, such as the gap between an out-of-pocket and insurance-reimbursed cost.
Justify Cost
The cost for the medical treatment, be it a device, drug treatment, or something else, must be approximately the same as other comparable devices, drugs, or treatments.
“Comparable” requires consideration of factors like the geographic location and the doctor’s experience. Inexperienced doctors in rural areas usually charge less than experienced doctors in urban areas. This disparity doesn’t mean one doctor is better than the other one. It just means one is more expensive than the other one.
Not all doctors are equal, and not all medical facilities are equal. Usually, treatments and procedures at small clinics are more expensive than similar treatments at large hospitals. High volume large hospitals charge less than smaller clinics. Additionally, doctors at smaller clinics usually focus on a particular area, such as work-related injuries.
When considering all the cost factors, a Tampa workers’ compensation lawyer can usually convince an ALJ that the medical treatment was reasonably necessary, from a cost perspective.
Work-Related Injury
Many injured workers have pre-existing or non-work medical conditions that contribute to the risk and/or severity of an injury.
If such an illness or injury was not work related, the treatment was not reasonably necessary for workers’ compensation purposes. Case closed.
However, if such an illness or injury contributed to a work-related injury, full benefits are usually available. These benefits include lost wage replacement along with payment of reasonably necessary medical bills.
Many factors directly or indirectly contributed to the Titanic’s sinking, like overconfidence in the ship’s construction and the ship’s excessive speed. However, the wreck had one substantial cause. It hit an iceberg.
In the workers’ compensation context, the line between a substantial and contributing cause is very fine. So, attorneys usually partner with independent doctors who draw this line.
Justify Treatment
Independent doctors also often testify as to the necessity of the therapy or treatment. Physical therapy is a good example. Some people immediately respond to physical therapy. Other people need more time, usually because the corrective surgery was more intense or they’re just different people.
Other times, the proof is in the pudding. If an unusually expensive procedure produced unusually positive results, that procedure was, arguably, reasonably necessary.
Usually, the workers’ compensation insurance company directly pays all reasonably necessary medical expenses. And, as mentioned above, the victim is not financially responsible for any unpaid costs. If the service was reasonably necessary, unpaid costs are a matter between the provider and insurance company.
Reach Out to a Savvy Hillsborough County Lawyer
Injury victims are entitled to important financial benefits. For a confidential consultation with an experienced workers’ compensation lawyer in Tampa, contact Kobal Law. We routinely handle matters throughout the Sunshine State.
