Mansell, Engel & Cole
  • Home
  • About
    • Steven S. Mansell
    • Mark A. Engel
    • Kenneth G. Cole
    • Keith F. Givens
    • Adam Engel
    • Zachary K. Housel
  • Practice Areas
    • Denied Claims & Disputes
    • Types Of Insurance
  • Case Results
  • Blog
  • Contact
Select Page

What is the definition of ‘medical necessity?’

On behalf of Mansell, Engel & Cole | Oct 3, 2016 | Insurance Disputes

Most of us do not work in the healthcare industry. We also don’t work in the health insurance industry. Therefore, when we are mere patients who receive those dreaded medical bills, it is natural that we get confused. 

Did you receive a medical bill and flinch when you saw the cost of a certain treatment? If you are like many Oklahoma residents, you probably thought a procedure was covered by insurance due to its necessity. 

The idea of “medical necessity” within the insurance industry is unfortunately more complicated than it initially sounds. 

So what does medical necessity technically mean?

According to a large health insurance provider, medically necessary treatment includes, “health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms.” 

The definition also notes how the treatment must be the standard of care according to the general industry standards. That standard includes the duration or frequency of a treatment. If there are other treatment options, the elected option must not only be proven to be reasonable and standard, but it must be comparable or lower in cost compared to other available, standard and proven options. 

 

When you are sick or injured and in need of medical relief, it is more than frustrating to have to try to understand insurance coverage and the cost to you and your family. Hopefully, you work with a healthcare provider whom you trust. If so, ask questions about standards of care and insurance coverage.

But even doctors can be uncertain about cost and insurance coverage. You can also talk to your insurance provider about treatment options and costs. They should be able to provide information about what treatment/procedures are covered by your plan. 

Sometimes, insurance providers are wrong. And sometimes, they act in bad faith. When that happens, an insurance lawyer can be your best advocate in order to defend your rights and your hard-earned money.

  • Facebook
  • Twitter
  • LinkedIn

Recent Posts

  • Fighting a denied earthquake insurance claim
  • Overview of Oklahoma’s bad faith laws
  • Common reasons why health insurance denies claims
  • When a life insurance company denies a claim
  • The importance of additional documentation after a denied claim

Archives

  • January 2021
  • December 2020
  • November 2020
  • October 2020
  • September 2020
  • August 2020
  • July 2020
  • June 2020
  • May 2020
  • April 2020
  • March 2020
  • February 2020
  • January 2020
  • December 2019
  • November 2019
  • October 2019
  • September 2019
  • August 2019
  • July 2019
  • June 2019
  • May 2019
  • April 2019
  • March 2019
  • February 2019
  • January 2019
  • December 2018
  • November 2018
  • October 2018
  • September 2018
  • August 2018
  • July 2018
  • June 2018
  • May 2018
  • April 2018
  • March 2018
  • February 2018
  • January 2018
  • December 2017
  • November 2017
  • October 2017
  • September 2017
  • August 2017
  • July 2017
  • June 2017
  • May 2017
  • April 2017
  • March 2017
  • February 2017
  • January 2017
  • December 2016
  • November 2016
  • October 2016
  • September 2016

Categories

  • Blog
  • Denied Insurance Claims
  • Firm News
  • Insurance
  • Insurance Disputes

RSS Feed

Subscribe To This Blog’s Feed

Start Your
Free Insurance
Claim Review

Mansell, Engel & Cole The Insurance Attorneys

Office Address

204 N. Robinson Ave.
21st Floor
Oklahoma City, OK 73102

Map & Directions

Get In Touch

Phone: 405-212-5921
Fax: 405-232-4140

  • Follow
  • Follow
  • Follow
IBFTLA - Insurance Bad Faith Trial Lawyers Association
Member of The National Trial Lawyers - Top 100 Trial Lawyers
AV Preeminent Rated Lawyers
Review Us

© 2021 Mansell, Engel & Cole. All Rights Reserved.

Disclaimer | Site Map | Privacy Policy | Business Development Solutions by FindLaw, part of Thomson Reuters