What is reasonable and necessary medical care in a worker's comp case?

Georgia law requires employers to provide medical benefits as part of workers' compensation for employees who've suffered on-the-job injuries. However, only reasonable and necessary medical expenses are covered.

Defining Reasonable and Necessary Medical Care

Under Georgia workers' compensation law, "reasonable and necessary" is thought to mean treatment in line with the standard of care for a specific condition.

For example, if you fell and broke your arm while delivering packages for FedEx or UPS, you'd expect to be provided with a diagnostic x-ray and a cast. If you sprained your ankle slipping on a wet floor while helping a customer at Lowe's or Home Depot, you'd expect to be provided with crutches and physical therapy exercises to help the injury fully heal.

Generally speaking, emergency room visits, basic diagnostic testing, limited physical therapy, and painkillers prescribed right after an injury are unlikely to be denied.

However, requests for coverage are often debated when medical expenses involve:

  • Specialized equipment with deluxe features not found on standard models
  • Modifications to the home to accommodate a disabling injury
  • Care provided by attendants with little or no medical training
  • Alternative treatments such as massage, yoga, acupuncture, chiropractic care, or water therapy
  • Surgery
  • Pain management
  • Psychiatric care
  • Extensive diagnostic testing
  • New and experimental treatments with little research to support their effectiveness
  • Duplicative treatments ordered by multiple doctors
  • Specialized treatment ordered by a non-specialist health care provider

Some of the expenses a workers' comp insurance company may attempt to deny may very well be medically necessary. For example, modifications to the home would be an excessive expense for an employee with a minor back injury, but a perfectly reasonable request for someone suffering from permanent paralysis.

The Value of Legal Representation

If you're having trouble getting workers' compensation benefits to include medical expenses you believe are reasonable and necessary, it's a good idea to contact an experienced attorney who can advocate for your needs. Letting an attorney negotiate on your behalf maximizes potential compensation while giving you more time to focus on recovery from your injury.

Rechtman & Spevak's legal team is committed to helping injured Georgia residents resolve their workers' compensation claims fairly and promptly.  Contact us today to schedule a free, no-obligation initial consultation.