After an accident, medical bills can stack up fast. You might assume the insurance company will pay everything, especially if your injuries are serious.
However, insurers don’t automatically accept the full cost of every treatment. Instead, they decide what they believe counts as “reasonable” medical expenses.
How insurance companies define “reasonable”
Insurance companies use their own guidelines to review medical expenses. They compare your bills to what similar services cost in your area. If a treatment seems too expensive or not directly related to the accident, they may reject it or only pay part of the cost. For example, if your doctor charges $300 for a physical therapy session but the average cost in your area is $150, the insurance company may only agree to pay the lower amount.
They also review how long you received treatment. If you visit a chiropractor twice a week for several months for treatment of whiplash, the insurer may decide that’s excessive unless your records clearly show a need for ongoing care. Insurance adjusters often look for patterns that don’t match what’s typical for your type of injury. They may flag duplicate services, overuse of expensive procedures, or any care they think wasn’t necessary.
What claimants should expect
Expect the insurance company to ask for detailed records. They may request doctor’s notes, medical reports, and receipts. They want proof that your treatment was needed and tied directly to the accident. If something in your records doesn’t match your injury claim, such as getting an MRI for a minor sprain, they may push back and refuse to cover it.
Even if your doctor recommends a certain type of care, the insurer may not cover it if it doesn’t fit their guidelines. Always keep copies of your medical documents and review your Explanation of Benefits (EOB) when you receive it. This shows what the insurance company paid and what they didn’t.
Understanding how insurers judge medical costs can help you stay prepared and avoid surprises. Knowing what they look for helps you make choices that won’t leave you stuck with unexpected bills.