What Constitutes Unreasonable and/or Unnecessary Treatment for Workers’ Compensation Injuries?

The New Jersey’s workers’ compensation system provides that employers and/or workers’ compensation insurance companies must pay for an employee’s reasonable and necessary medical treatment causally related to a work injury. In other words, if you are injured on the job, the law says that you do not need to pay for resulting medical expenses out of your own pocket.

However, this protection does not come without limitations. First, insurance companies are only responsible for payment of medical treatment that is directly related to the work injury. Second, the insurance company is only required to pay for related medical treatment that is reasonable and necessary.

And, as you may suspect, injured employees and insurance companies sometimes have very different opinions as to what the phrase “reasonable and necessary” actually means. If you are fighting with your employer or the insurance company over medical treatment coverage, contact the experienced workers’ compensation legal team at Petro Cohen, P.C. to discuss your case. We can help.

What is considered reasonable and necessary medical treatment?

If an insurance company has decided to accept your workers’ compensation claim, there are some common types of medical care and treatment that it generally will accept as reasonable and necessary, which includes the following:

• Doctor appointments
• Diagnostic testing (such as x-rays, ultrasounds, and MRIs) if such testing is medically necessary to diagnose the exact nature of the injury
• Certain hospital services
• Certain medications (administered and prescribed)
• Certain surgeries
• Certain medical devices (such as wheelchairs, splints, crutches, hearing aids, etc.)
• Certain finite periods of physical therapy

What may be considered unnecessary and/or unreasonable?

In some cases, insurance companies argue that certain types of treatment are almost never reasonable and/or necessary, such as the following:

• Any medical treatments that your doctor actually states are unnecessary to treat your work-related injury
• New, experimental, or prohibitively expensive drugs or treatments
• Acupuncture and other alternative medical therapies
• Chiropractic care
• Treatment that is inconsistent with the injury and diagnosis
• Extensive treatment for subjective and/or minor injuries
• Duplicative treatment (for example, the same treatment ordered by different doctors)
• Certain specialized treatment ordered by a non-specialist
• All medical treatment for soft-tissue injuries after three weeks

In the vast majority of cases, good doctors only order treatments which they believe are reasonable and necessary. Unfortunately, your insurance company may disagree and refuse to pay for the treatment.

All hope is not lost

If an insurance company denies payment for medical treatment that you believe you need and deserve – including but not limited to additional or continued treatment, treatment that happens to be expensive, and second opinions – the amazing workers’ compensation legal team at Petro Cohen, P.C. can help.

We can review your claim, conduct legal research, consult with our medical experts, and, if necessary, file a Motion for Medical Treatment. We have extensive experience in this area, not to mention a very successful track record in obtaining medical treatment for our clients that insurance companies have wrongfully denied.

Contact Us Today

At Petro Cohen, P.C., we can help you take on unreasonable employers and workers’ compensation insurance companies. We understand how insurance companies operate, and we will do everything in our power to ensure that your rights are protected – including the right to obtain medical treatment you need and to which you are entitled.

Call or contact us today for a free consultation. We can be reached by phone at 888-675-7607, or you can complete our online form.