What Are “Reasonable” Medical Expenses?

July 2, 2019

Under the Pennsylvania Workers’ Compensation Act (the Act), an employee who sustains a work-related injury or illness may file a claim for workers’ compensation benefits. If the claim is accepted, the employee will begin receiving benefits, including payments for reasonable and necessary medical expenses related to the work injury or illness. Given the subjective nature of this provision, many workers wonder – what does “reasonable” medical expenses mean?

Examples of Reasonable Medical Expenses

Medical expenses that are reasonable, necessary, and related to the work injury or illness typically include:

  • Hospital tests and services
  • Medical supplies and devices
  • Medicine
  • Orthopedic appliances
  • Prosthesis
  • Rehabilitation treatment/physical therapy
  • Surgeries
  • Travel expenses to and from the doctor

Court Interpretation

Generally, the Pennsylvania Commonwealth Court (the court) interprets the Act liberally, in accordance with the Act’s humanitarian purpose. There are many instances in which the court has approved unusual requests for reasonable medical expenses, such as payment for:

  • a modified van for a quadriplegic; or
  • artificial insemination for a claimant who suffered loss of sexual function due to a spinal injury.

However, the court is also aware of the possibility of windfalls and it tries to avoid an unfair outcome by considering whether alternative means exist. For example, in one case the court denied a claimant’s request for the installation of an aquatic therapy pool at his home because he was able to travel to a physical therapy facility for aquatic therapy.

Efforts to Minimize Medical Costs

Medical costs have risen significantly in recent years, due to both inflation and an increase in worker injuries. The Act provides several methods to keep workers’ compensation medical costs down, including:

  • Providing a list of designated health care providers – Employers have the option to provide an injured worker with a list of at least six designated health care providers. The worker must receive treatment from his or her choice of these designated providers for at least the first 90 days.
  • Requesting a Utilization Review – Either party may request a Utilization Review by an unbiased, third-party health care professional if they believe a treatment is not necessary or reasonable. The utilization review organization (URO) will then decide whether the challenged treatment should be compensable.
  • Requesting an Independent Medical Evaluation (IME) – Employers may hire a physician to evaluate the worker’s condition and give an expert opinion regarding several issues including the severity of the injury, the prescribed treatment plan, and any available less expensive options.
  • Utilization of Peer Review – Cases that are in litigation are subject to peer review at the request of either party or the judge. A peer review is when an expert examines the employee or their medical records and renders an opinion as to whether the treatment is compensable.

Philadelphia Workers’ Compensation Lawyers at Larry Pitt & Associates, P.C. Help Workers Collect Reasonable Medical Expenses and Other Benefits to Which They Are Entitled

If you were injured in a workplace accident or you developed a work-related illness, contact a Philadelphia workers’ compensation lawyer at Larry Pitt & Associates, P.C. You may be eligible for workers’ compensation benefits, including reasonable and necessary medical expenses and lost wages. Our knowledgeable attorneys proudly serve clients in Philadelphia and throughout the state. For a free consultation, please complete our online contact form or call us at 888-PITT-LAW today.

We are proud to represent clients in Berks CountyBucks CountyChester CountyDelaware CountyMontgomery CountyPhiladelphia County, and throughout Pennsylvania, including those in the communities of AbingtonAmblerArdmoreBala CynwydBensalemClifton HeightsCrum LynneDarbyDowningtownDoylestownDrexel HillEssingtonFolcroftGlenoldenHaverfordHavertownHolmesKutztownLansdowneMediaMerion StationMortonNarberthNorristownNorwoodPhiladelphiaProspect ParkQuakertownReadingRoxboroughSharon HillUpper DarbyWest Chester, and Wynnewood.