413.4 Issues on Claim

413.4 Issues on Claim a. Issues generally: (Plaintiff) seeks personal injury benefits from (defendant) for [a medical service] [medical services]. (Plaintiff) is entitled to [recover benefits] [receive payment] if the service[s] [is] [are] related to the accident, the service[s] [is] [are] medically necessary, and the charge[s] for the service[s] [is] [are] reasonable. Give the following preemptive instruction only where rulings or stipulations have altered the number of issues to be proven. In this case, there is no dispute that [the service[s] [is] [are] related to the accident] [and] [that the service[s] [is] [are] medically necessary] [and] [that the charge[s] [is] [are] reasonable], but there is dispute over [whether the service[s] [is] [are] related to the accident] [and] [whether the service[s] [is] [are] medically necessary] [and] [whether the charge[s] for the service[s] [is] [are] reasonable]. Give the following instruction in all cases. Alter numbering where required due to rulings or stipulations. Therefore, on this claim for personal injury benefits, you must decide the following: The first issue is whether the service is related to the automobile accident of (date). If you decide that a service is not related to the accident, you should not award damages for that service. If you decide that one or more services are related to the accident, you must then decide a second issue. The second issue is whether the service is medically necessary. If you decide that a service was not medically necessary, you should not award damages for that service. If you decide that one or more services are medically necessary, you must then decide a third issue. The third issue is whether the charge is reasonable. If you find the charge for a service or services reasonable, you should award that amount as damages. If you find the charge for a service or services is not reasonable, you should award an amount that the greater weight of the evidence shows is reasonable. In determining [these] [this] issue[s], you should apply the following definition[s]: Give applicable definitions below. b. Services: The term "services" includes, but is not limited to, treatment, diagnostic studies, and supplies provided by the medical provider to the insured. c. Medically Necessary: "Medically necessary" refers to a medical service or supply that a prudent physician would provide for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptom in a manner that is: (1) In accordance with generally accepted standards of medical practice; (2) Clinically appropriate in terms of type, frequency, extent, site, and duration; and, (3) Not primarily for the convenience of the patient, physician, or other health care provider. d. Reasonable Charge: In deciding whether the amount of a charge is reasonable, you may consider evidence of: (1) (2) (3) (4) usual and customary charges and payments accepted by the provider involved in the dispute; reimbursement levels in the community; reimbursement levels in various federal and state medical fee schedules applicable to automobile coverages; and any other evidence relevant to the reasonableness of the charges. You may not, however, award an amount that exceeds the amount the provider customarily charges for like services or supplies.