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Can Insurance Companies Exclude Specific Medical Bills from My Claim?

Posted on October 13, 2021 in

Those who have suffered injuries in a car accident through no fault of their own may feel blindsided when insurance companies try to exclude specific medical bills from their claims. That’s one reason why consulting with an Arizona personal injury attorney like those at the Jensen Phelan Law Firm can help. Our personal injury lawyers are experts in evaluating personal injury cases, teaching clients which medical expenses are covered and how to prove these damages.

Insurance companies usually agree to cover those medical expenses that fall under the term “necessary and reasonable” (a medical question) but only if the cause of the treatment is for the accident injuries. Will your medical provider support that the treatment rendered was necessary to care for the injuries (and not for something else) and that the amount charged is reasonable in light of what other similarly situated medical providers charge for the same services.

If there is a pre-existing condition that involves the same body part or area, insurers often refuse to pay for the medical expenses. The tricky part can be when disagreements arise over what exactly qualifies as necessary and reasonable treatment for you accident injuries (will your doctor support that in writing?) and whether there are past medical records that indicate you had all or some part of the same symptoms from a prior cause.

What Proof of Injury Causation is Needed?

It is very common for insurance companies to claim that the cause of the medical treatment expense (“causation”) is something unrelated to the accident, or perhaps partially unrelated to the accident. This is where an experienced and capable attorney is especially important because medical proof of this type is often medically complex and difficult to obtain as doctors often do not wish to become involved in an insurance claim injury case.

What Are Generally Considered “Necessary and Reasonable Medical Expenses”?

“Necessary” medical treatment. Differing interpretations may come into play after one of our clients suffers a personal injury in a car crash or other type of accident. When it comes to serious internal injuries resulting in prompt surgery, it’s often hard to argue that a victim did not require the surgery to adequately treat their wounds. In some cases, however, medical professionals may have opposing viewpoints on exactly what course of treatment is necessary for accident recoveries.

Insurance companies may argue that certain medications were prescribed for too long a duration or that some follow-up doctor visits may have been unnecessary. This is when an experienced attorney can help a victim obtain the necessary backup for their claims, including having medical professionals testify as to the validity of the prescribed treatment.

In situations where accident victims want to try new medical procedures not yet widely accepted, alternative medicine or perhaps risky medical procedures that aren’t well accepted in the medical community to be more likely to improve someone’s medical outcome compared to cheaper or more traditional surgeries, insurance companies will almost always dispute this with their medical experts. In some life-threatening or serious instances, however, such a risky surgery may be the best and only treatment choice but will still be disputed for payment.

“Reasonable” Costs of Treatment. Establishing that a particular treatment course was necessary is only half the battle. You will typically also need to prove that the fees for a particular treatment option are comparable to how much other medical professionals would charge for the same or similar services. Insurance companies may only agree to cover part of the expense if your provider charges significantly more than what other providers charge.

Do Insurance Companies Need to Cover Future Medical Expenses?

Those accident victims who incur significant and permanent injuries or disabilities often worry about covering the costs of future medical expenses. If you fall into this category, you may be able to seek compensation for those future medical costs which can be large in amount over many years. That “reasonable and necessary” term also applies to these types of medical expenses. Insurers do not like to pay for these future expenses because “the future treatment may never happen.”

You will likely need to prove why you’ll need that particular treatment course in the future and its estimated expense. This usually consists of showing that it’s the standard form of treatment for patients with a similar diagnosis. Seeking a more unusual treatment course or surgical procedure than what is generally prescribed for someone with your diagnosis often results in the insurance company denying that portion of your claim.

Obtaining a full and fair recovery for future medical expenses is often not obtainable without the help of an experienced personal injury attorney to help you get expert opinions supporting your claims, provide the documentation to substantiate your claims for future medical expenses and persuade the reluctant insurer that “you can pay us now or pay us later.” Without a good lawyer, the insurer will not be impressed by most claims for future medical expenses. Keep in mind that insurance companies will often try to lowball accident victims, so having an attorney fighting at your side helps you maximize the amount of future damages compensation you receive.

Contact the Personal Injury Attorneys at Jensen Phelan Law Firm

If you worry that insurance companies will exclude specific medical bills from your claim, the personal injury attorneys at Jensen Phelan Law Firm can help. We’ve been fighting for our client’s rights to receive compensation for injuries caused by another’s negligence for decades. Call us at (928) 778-2660 or contact us online to schedule a convenient, no-cost consultation.