What Is Considered Reasonable and Necessary Treatment in an Insurance Claim?

reasonable and necessary treatment for an injured accident victimIf you have been seriously injured in an accident, your insurer is supposed to pay for any reasonable and necessary medical treatment not covered by Ontario’s health care plan or group insurance plan, up to the policy limits.

But what is deemed reasonable and necessary treatment? And how can this be proven to an insurer in order to get compensated for your injuries? This process will require several different factors, including certain medical evidence from your treating doctor. Otherwise, the insurance company may say that your injuries are not as serious as you claim and reject paying for the medical costs you have incurred.

If you have a valid claim, our legal team is ready to collect and present evidence to establish that your medical treatment has been reasonable and necessary to aid in your recovery. The initial consultation costs nothing and you are under no obligation to hire our firm. We only get paid if you get paid.

Medical Treatment Covered by Insurance Companies

The Statutory Accident Benefits Schedule (SABS) is a mandatory no-fault auto insurance coverage in Ontario and is included with all basic auto insurance policies.

The medical and rehabilitation benefit under SABS provides coverage for reasonable and necessary medication and rehabilitation costs not covered by health care, such as:

  • Acupuncture
  • Ambulance services
  • Chiropractic care
  • Counseling
  • Massage therapy
  • Mobility devices
  • Occupational therapy
  • Physiotherapy
  • Prescriptions
  • Rehab support

Proving Your Treatment is Reasonable and Necessary

Being able to receive medical treatment for an injury is important for anyone’s recovery after an accident. Treatment can alleviate pain and improve movement and function impaired by an injury.

However, an insurer may deny paying for your medical treatment if they believe that your incurred costs you have incurred are not reasonably associated with the injuries you are suffering from.

Determining what treatment is reasonable and necessary after an accident can be difficult, which is why hiring an experienced lawyer may benefit your claim. A Windsor-based personal injury lawyer from our firm is prepared to review your claim to determine if your insurance company is acting in bad faith and the legal options available to you.

What is considered reasonable and necessary treatment will vary on a case-by-case basis. Your unique circumstances, including your insurance policy and treating doctor, will be taken into account to determine whether any treatment provided is absolutely essential.

Case law has generally held that reasonable and necessary treatment should have identified, reasonable goals. In other words, any goal set must be met to a reasonable degree. For instance, if one of the treatment goals for an injured accident victim is to help alleviate (rather than eliminate) pain so he or she can participate in normal daily activities, the recommended treatment will likely be deemed reasonable and necessary.

The cost-effectiveness of treatment is also important. If the overall costs (not just money, but time) for the treatment is high but the degree of success is low, the treatment will unlikely be considered reasonable and necessary. Treatment that may cause further injury is also unlikely to be reasonable.

A lawyer can help you gather the objective medical evidence needed to show that your treatment is reasonable and necessary. This can include medical exams, tests, diagnostic imaging and other types of documentation provided by your treating doctor to establish the seriousness of your injuries.

Reach Out to Our Firm to Get Started

Proving your medical treatment is both reasonable and necessary and getting the compensation needed to pay for these costs can be challenging. At Greg Monforton and Partners, we know how insurance companies think. We have decades of experience handling claims on behalf of clients to seek the maximum compensation possible.

Our initial consultations are 100 percent free and come with no obligation to retain our services. Since we work on a contingency fee basis, our firm receives no payment unless we help you obtain a recovery.

Call (866) 320-4770 for answers to your legal questions today.