Updated on April 19th, 2023
Brad Nakase, Attorney
Insurance companies are involved in nearly all personal injury lawsuits; insurance companies are notorious for fighting medical expenses. The insurance companies are backseat drivers of doctor’s recommended treatment plans. There is no doubt that you haven’t encountered such funding denials. Especially if you are a health care professional working with injured vehicle accident victims under California’s statutory accident benefit system.
Commonly, the insurers oppose the treatment plan, arguing that the plan was not “necessary and reasonable:” Putting in mind that the “necessary and reasonable” notion is the base of eligibility for rehabilitation and medical benefits.
Unluckily the notion “necessary and reasonable” does not appear anywhere in the legislation. This is because it varies from one case to another and, more so, differs from the clinical professional disciplines. Hence it’s challenging to determine what constitutes “necessary and reasonable,” making words ambiguous.
To determine “reasonable” treatment proves to be complicated. Can you measure, or set a degree to act as a determinant of “reasonable treatment?” Does it imply that any “reasonable” treatment depends on a particular type of injury? Over time it has proved difficult since; there is risk, benefit, cost, and trust involved.
On the other hand, to determine what “necessary” treatment is, it also proves to be a significant challenge. Is it implying that the treatment has to be undeniably indispensable? Can the treatment which poses uncertainties be essential or necessary?
Overall, there seems to be no direct answer to address the concerns. Every concern appears to depend on its evidence. However, the case law provides some guidance over the same. Objective medical evidence that equally majors its interest in the effectiveness of the treatment a requirement. An injured person’s certainty in the benefits of the treatment, in the long run, proves to be insufficient.
Furthermore, in case the treatment causes further injuries, then there is a high probability of terming it not reasonable. However, in case the therapy brings forth good results, there is a 100% chance of treating it “reasonable.” But it now depends on whether the plaintiff will accept such treatment.
Duration for treatment, as well as rate of recurrence, counts a lot. Treatment, which takes a short time, incorporated with periodic re-evaluation, is termed necessary and reasonable. One has to demonstrate that the effectiveness of the given treatment procedure is certain.
Lawyers term the evidence “necessary and reasonable” in case the injured person proves no evidence of progress from previous benefits.
If a particular treatment only has insignificant or modest benefits, it is unlikely to be termed “necessary and reasonable.”
The primary aim of the treatment may not necessarily lead to full recovery. Nevertheless, its considered “reasonable and necessary” if the treatments lead to even temporary relief to the injured person.
In one case, it was discovered that reducing stress, which equally relieves anxiety and depression, was reasonable and necessary.
Likewise, if reducing pain is one of the significant concerns, the treatments are accepted as reasonable and necessary. Since lowering the pain might help the injured person engage in other activities in the process.
On the other hand, an adjudicator found it not “reasonable and necessary” to one of the treatment plans. The treatment plan didn’t provide the means which would “resolve” the pain hence terming it not “reasonable and necessary.”
Researchers term the treatment not reasonable and necessary if the treatment plan results in the over-dependence of the treatment plan. It is because the treatment plan, which one expects to relive the pain, results in inappropriate over-dependence.
In case the proposed rehabilitation measure shows an effective way of improving the quality of life of the injured person, it’s considered reasonable and necessary.
Another relevant aspect is the cost-benefit of the proposed treatment. Most lawyers’ term not reasonable and necessary when the cost-benefit if high, but the result is low. Generally, adjudicators find it essential that the cost-benefit treatment plan is proportionate to the needs of the injured person.
Conclusively every case depends on its circumstance and facts. There are not perfect means to relate the reasonability of any treatment plan to the injured person or insurer.
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