How to Rebut the Presumption of Reasonableness and Necessity of Medical Bills in an Injury Suit

By: Tanner Gibson, Senior Associate - Meridian Law

Staying up to date on the rules regarding the admissibility of medical records and bills is critical for personal injury law practitioners and clients. Plaintiffs can take advantage of certain evidentiary presumptions regarding the reasonableness of their bills. However, this does not necessarily mean that it is easy for personal injury plaintiffs to prove their case. Recent decisions by Tennessee courts have clarified the law and highlighted hurdles to admissibility. Navigating these hurdles can make or break a case for businesses and individuals defending against personal injury lawsuits. These hurdles are discussed in more detail below.

A Rebuttable Presumption of Reasonableness

For relatively low medical bills, an injured party may establish a presumption that costs for their treatment were reasonable if the party itemizes and attaches bills for their treatment to the complaint. However, this presumption only applies to medical costs up to $4,000.00.[1]

For an allegedly injured plaintiff to establish that costs for their care of any amount were reasonable, the plaintiff must serve the itemization and copies of their bills upon the defendant or other parties to the lawsuit at least 90 days before trial.[2] However, this act only creates a presumption that costs for their treatment were reasonable, and presumptions can be rebutted. Failing to rebut this presumption allows the jury to properly assume that any costs for a plaintiff’s injury-related treatment must have been reasonable. A defendant facing an injury lawsuit can combat this presumption by serving a statement of intent to rebut that reasonableness at least 45 days before trial and then introducing evidence to rebut reasonableness at trial.[3]

The Question of Necessity

Until recently, Tennessee law left open the question of necessity: Can a plaintiff also establish a presumption that treatment costs were necessary simply by serving copies of the medical bills? In its July 28, 2023 opinion in Holzmer v. Estate of Walsh,[4] the Tennessee Court of Appeals answered this question in the negative.

In Holzmer, a jury trial had been held only on damages suffered from the plaintiff’s car crash. The plaintiff’s expert physician testified that the plaintiff’s treatment was both reasonable and necessary but did not opine on the expenses. The plaintiff called lay employee witnesses from three treatment facilities, each of whom testified about medical billings and the cost of treatment, but could not testify about the necessity of the charges.[5] The trial court excluded all proof of medical bills because the plaintiff did not have an expert witness testify to the costs of her treatment being necessary. Plaintiff appealed.

The appellate court agreed with the trial court, finding that the elements of necessity and reasonableness were distinct and must be separately proven: “Therefore, even when a plaintiff is entitled to the statutory rebuttable presumption of reasonableness of medical expenses, there is no presumption regarding the necessity of the care and expenses described in the bills.”[6]

Expert Knowledge

Another route to challenging the reasonableness and necessity of a plaintiff’s treatment and costs is to question the foundational knowledge of their expert witnesses.[7] A physician who seeks to testify that another physician’s treatment was necessary and that the charges were reasonable must demonstrate the following:

1.    Knowledge of the party’s condition.

2.    Knowledge of the treatment the party received.

3.    Knowledge of the customary treatment options for the condition in the medical community where the treatment was rendered.

4.    Knowledge of the customary charges for the treatment.[8]

Plaintiffs must ensure that they offer sufficient testimony on these points, or else defendants may seek to exclude or limit the evidence that can be admitted.

Collateral Source Rule

When rebutting the presumption that a plaintiff’s medical expenses were reasonable, defendants must be mindful of the collateral source rule, which keeps out evidence that a plaintiff had their bills paid or reduced from other sources.[9] In other words, defendants cannot hope to show that a medical bill was unreasonable because insurance paid less than that amount.

The Tennessee Court of Appeals addressed this situation in its 2021 opinion Doty v. City of Johnson City.[10] In Doty, the trial court excluded the testimony of two witnesses for the defense who stated that the plaintiff’s bills were unreasonably high. One doctor testified at deposition that there is “a large difference between the typical bill that is sent for medical services…and what is reflected in reality with the money that changes hands.”[11] The second witness had a graph comparing a hospital’s billed charges with payment amounts accepted from third parties. The appellate court wrote this was the “very type of evidence prohibited by the collateral source rule” and upheld its exclusion.[12]  

Future Medical Treatment

The presumptions discussed above do not apply to a plaintiff seeking to prove future treatment and costs, given that bills for future treatment cannot be itemized and served upon the opposing party. For a Tennessee plaintiff to be awarded damages for the cost of future medical treatment, the plaintiff must present the following:

1.     Proof that additional medical treatment is reasonably certain to be required in the future.

2.     Support that will enable the trier-of-fact to reasonably estimate the costs of the expected treatment.[13]

Otherwise, an award for future expenses would come “from the realm of speculation.”[14]  The reasonable certainty standard requires the plaintiff to show that future medical treatment will “more probably than not” be needed.[15] 

The Court of Appeals’ opinion in Singh v. Larry Fowler Trucking, Inc.[16] demonstrated this burden by examining an orthopedic surgeon’s deposition testimony on the plaintiff’s future treatment and costs. The trial court had excluded the surgeon’s testimony, finding he did not have competent knowledge of the plaintiff’s future surgery needs or costs.[17]The appellate court agreed the doctor’s testimony had not demonstrated reasonable medical certainty of future surgery needs and upheld the trial court’s ruling.[18]

Conclusion

Despite the statutory presumption in favor of plaintiffs, defendants who make effective use of expert testimony and the rules of evidence greatly increase their chances of a favorable settlement or verdict. Tennessee courts have shown ways to challenge both the reasonableness and the necessity of excessive treatment costs in personal injury cases.

We Can Help

If you or your business are facing an injury lawsuit, the experienced team at Meridian Law can protect your rights and interests up to and through trial. Please do not hesitate to contact our team with questions at (615) 229-7499, by email at info@meridian.law, or through our contact form at www.meridian.law.

Disclaimer: The information in this blog post (“post”) is provided for general informational purposes only and may not reflect the current law in your jurisdiction. No information in this post should be construed as legal advice from Meridian Law, PLLC, or the individual author, nor is it intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting based on any information included in or accessible through this post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country, or other appropriate licensing jurisdiction.

[1] Tenn. Code Ann. § 24-5-113(a)(3).

[2] Tenn. Code Ann. § 24-5-113(b)(1).

[3] Tenn. Code Ann. § 24-5-113(b)(2).

[4] No. M2022-00616-COA-R3-CV, 2023 WL 4836691 (Tenn.Ct.App. 2023).

[5] Id. at *6 n.5.

[6] Id. at *6.

[7] See Borner v. Autry, 284 S.W.3d 216, 218 (Tenn. 2009) (“In all but the most obvious and routine cases, plaintiffs must present competent expert testimony to meet this burden of proof.”).

[8] Dedmon v. Steelman, 535 S.W.3d 431, 438 (Tenn. 2017) (citing Long v. Mattingly, 797 S.W.2d 889, 893 (Tenn.Ct.App. 1990)).

[9] Id. at 433.

[10] No. E2020-00054-COA-R3-CV, 2021 WL 2822186 (Tenn.Ct.App. 2021).

[11] Id. at 2.

[12] Id. at 3.

[13] Henley v. Amacher, No. M1999-02799-COA-R3-CV, 2002 WL 100402 at *13-15 (Tenn.Ct.App. 2002).

[14] Id. at *15.

[15]  Singh v. Larry Fowler Trucking, Inc., 390 S.W.3d 280, 287 (Tenn.Ct.App. 2012).

[16] See generally, id.

[17] Id. at 283.

[18] Id. at 288.