What Medical Expenses Are Considered Reasonable and Necessary?

If you suffered injuries in a wreck that was caused by the negligence of someone else, you can seek compensation from the at-fault party. In the case of automobile collisions, the Personal Injury Protection (PIP) component of your auto insurance policy will cover you for reasonable and necessary medical expenses up to a limit of $4,500 (unless you have purchased additional coverage).

Once your medical bills exceed that amount, or if your injuries were not sustained in a car crash but instead were the result of a faulty product, workplace mishap, or a slip and fall incident, you can seek compensation from the insurance company of the at-fault party.

However, no matter what caused your injuries, when it comes to treatment costs, the insurance company will only pay for reasonable and necessary medical expenses. In fact, you can be very certain that at some point the insurance company will try to dissect your claim for the reasonableness and the necessity of the medical expenses. So, continue reading to know what these terms mean and what you can do to ensure that you don’t walk into this trap.

What medical expenses are covered by the insurance company of the at-fault party?

The insurance company of the at-fault party is liable for compensating you for any medical expenses incurred to treat injuries that were a result of his/her/their insured’s negligence. In the line of treatment, this could be:

• Ambulance cost
• ER treatment
• Diagnostic tests
• Hospital stay
• Specialist fees
• Surgical costs
• Nursing care
• Rehabilitation sessions
• Prosthetics
• Medication
• Follow up treatment and checkups
• Physical therapy (continual)

In addition to this, the plaintiff is also eligible to receive compensation for future/anticipated medical costs that are likely to arise as a result of ongoing treatment of the injuries sustained, or from a permanent or long-term disability caused by such injuries.

All of that is required, so what exactly is unnecessary in these expenses?

You file a claim because your injuries and their after-effects were the results of a wreck that occurred due to the negligence of the defendant. So, necessary medical expenses are those that arise in the strictest sense from the injuries caused by the acts of the negligent party, and not the treatment costs that resulted from an existing or prior medical condition.

For example, a victim who has suffered a traumatic brain injury due to a motor vehicle collision can definitely seek compensation for all medical costs incurred to treat the condition. But, suppose this individual was a pro-athlete who had suffered a concussion or two in the past. In this case, the defense is bound to argue that the effects of the brain trauma are a ramification of the injuries suffered in the past and not those sustained due to the wreck.

Consider another example – An individual who suffers a fracture due to a fall and has a history of arthritis. Once again, the defense will pin the blame for the broken bone not on the fall, but on the poor bone density of the victim.

And that is how they will prove that since the injury did not result from the accident, the medical cost associated with the treatment cannot be considered necessary from the compensation point of view.

And what about the reasonableness of the medical expense?

The factors that constitute reasonable medical expenses have been interpreted in varying ways by different courts. Generally, as long as the cost of the medical procedure is within the normal range (at par with similar treatment costs across the state and the country), the expense would be considered reasonable.

When discussing reasonableness, there is also the difference between the bill amount and the actual money paid to be considered. In Kansas, the Collateral Source Rule allows the jury to consider the following to determine reasonable medical expenses:

• The billed medical expenses;
• The actual amount paid after write-offs; and
• The portion of the bill that has yet to be paid (ongoing treatment).

Typically, the figure is somewhere in between those three components. Of course, the defense is bound to argue that if a portion of your medical bill has already been paid, their liability should no longer be as much as it was when you filed the claim. 

For example, assume that the hospital raised a billed amount of $20,000 to treat your injuries, and you are expected to need another $5,000 worth of treatment in the near future. Your health insurance stepped in and after write-offs, discounts, etc. they paid $15,000 of the bill.

So, when you file a claim for the total billed amount of $25,000, the defense is bound to argue that although you were billed $25,000 initially, your current bill only stands at $5,000. Hence, they should only be held liable for the current amount.

This isn’t a battle that you should handle on your own!

If your medical bills run into tens of thousands of dollars, don’t assume that just because you have documented proof of the money spent on treatment, that the insurance company on the other side will simply pay up.

Get in touch with DeVaughn James Injury Lawyers right away and we will make sure that you receive the compensation that is rightfully yours.