“Reasonable And Necessary” Treatment: What Does It Mean?

Your automobile insurer is supposed to pay for all “reasonable and necessary” non-OHIP-covered medical treatment (up to specific monetary limits).  This includes things like:

  • Physiotherapy
  • Counseling
  • Occupational Therapy
  • Rehab Support
  • Chiropractic
  • Acupuncture
  • Massage Therapy and
  • Mobility devices

Treatment is important for any person’s recovery from injury.  Treatment can alleviate pain and increase function.

But, often automobile insurers will balk at paying for treatment, stating “that’s not reasonable and necessary”.  Injury victims and treatment providers are left wondering, what does “reasonable and necessary” really mean?

The case law has held that to be “reasonable and necessary”, treatment should:

  • Have identified, reasonable goals
    • The goals are being met to a reasonable degree
    • The overall costs (not just financial, but also time invested) of achieving the goals is reasonable taking into consideration both the degree of success and the availability of other treatment alternatives[1]

For treatment providers, it is important to state how the treatment meets the “reasonable and necessary” criteria.

Pain relief is one of the most common goals of treatment.  So, what about pain relief?  Is treatment that provides pain relief “reasonable and necessary”?  The answer is:  Yes.

The relief of pain is a valid and recognized goal of health care professionals.  In some sad cases, it can be the only goal.  And, the case law has held that pain relief is “reasonable and necessary”.[2]

[1] Violi v. General Accident, FSCOAD, 2000

[2] Violi v. General Accident, FSCOAD, 2000