“Reasonable & Necessary”: How is it Defined?

“Reasonable & Necessary”: How is it Defined? Image

Imagine sustaining an injury at work—perhaps due to faulty equipment or in the course of your daily responsibilities. The first thoughts that likely rush through your head are not just about your health but also about the maze of legal complexities you’re about to navigate.

In this situation, terms like reasonable and necessary may float to the surface as you discuss your medical treatment and workers’ compensation claim. Understanding these terms is crucial to receiving the compensation you rightfully deserve.

What is the Reasonable and Necessary Standard?

The reasonable and necessary standard is a legal concept that is used to determine whether a particular treatment or service is covered by workers’ compensation. To be considered reasonable and necessary, a treatment or service must meet the following criteria:

  • It must be related to the worker’s work-related injury or illness.
  • It must be likely to be effective in treating the injury or illness.
  • It must be the least expensive treatment that is likely to be effective.
  • It must be available in the worker’s community.

How is the Reasonable and Necessary Standard Applied?

The OWCC will apply the reasonable and necessary standard on a case-by-case basis. The specific factors that the OWCC will consider will vary depending on the particular case. However, some of the factors that the OWCC may consider include:

  • The severity of the worker’s injury or illness.
  • The worker’s age and medical history.
  • The worker’s occupation.
  • The availability of alternative treatments.
  • The cost of the treatment.

In Oklahoma workers compensation cases, the medical treatment must align with the guidelines and recommendations issued by medical boards and authoritative entities such as the American Medical Association. Non-compliance with these guidelines may result in the denial of a workers’ compensation claim (“Oklahoma Administrative Code §810:15-3-10”).

Compensation Approval and Scrutiny

Often, claims go through rigorous scrutiny where every medical procedure, prescription, and consultation is weighed against the reasonable and necessary criteria. In some cases, the Oklahoma Workers Compensation Court may require an independent medical examination to establish the reasonableness and necessity of a treatment.

Tips for Getting the Benefits You Deserve

If you have been injured on the job, it is important to understand the reasonable and necessary standard. This will help you to know what types of benefits you can expect to receive.

Here are some tips for getting the benefits you deserve:

Seek Immediate Medical Attention. Immediate medical attention not only protects your health but also creates a real-time record that can later prove crucial. This initial medical record can establish a direct link between your injury and your occupation, an essential factor in workers’ compensation claims.

Maintain Comprehensive Medical Records. Retain all bills, prescriptions, medical reports, and any other related documentation. These records serve as tangible proof that your medical expenses are both reasonable and necessary. Incomplete or disorganized records can lead to delayed or denied claims.

Engage a Workers’ Compensation Attorney. The value of an experienced Oklahoma workers compensation attorney from the Burton Law Group cannot be overstated. They will represent you during any disputes, appeals, or negotiations with insurers.

Understand Your Work-Related Benefits. Besides medical costs, workers’ compensation may also cover other work-related losses, such as lost wages. Thoroughly review your policy or consult your attorney to understand what types of benefits you may be eligible for. This ensures you claim all the advantages you’re entitled to, not just medical expenses.

Be Prepared for Independent Medical Examinations. Sometimes, the Oklahoma Workers Compensation Commission or your employer’s insurance may request an independent medical examination (IME). Treat this examination with utmost seriousness. Any inconsistencies between the IME report and your own medical records could jeopardize your claim.

The Role of a Workers Comp Attorney

Decoding the intricacies of what is reasonable and necessary is far from straightforward. This is where services offered by the Burton Law Group come into play. With a wealth of experience in Oklahoma workers compensation cases, a Tulsa workers comp attorney can guide you through the process, ensuring you take all the right steps and make all the right moves.

Legal representation can help you collate all the required evidence, prepare the paperwork, and argue your case, significantly increasing the likelihood that your claim will be deemed both “reasonable and necessary” by the Oklahoma Workers Compensation Court. From scrutinizing medical records to countering the arguments of insurance adjusters, a worker’s comp injury attorney can provide a strategic approach to your case.

Ready to take the next step? Contact the Burton Law Group for a consultation.