By Marc Diller, Esq.
DILLER LAW, LLP
Medical Treatment – Questions & Answers
1. Even if at fault for causing an automobile accident, can the injured person receive insurance coverage to pay accident-related medical bills?
Yes! Regardless of fault, those persons injured in a Massachusetts automobile accident can recover from any available PIP, Health and/or Med Pay coverage.
2. Where does the injured person access Personal Injury Protection (“PIP”) automobile coverage for payment of auto accident-related Medical Expenses?
In Massachusetts, generally, if the person injured has an auto accident, such injured person should be entitled to accident-related medical expenses coverage under PIP regardless of fault. The insurance policy responsible for covering the injured person’s PIP benefits is:
First, the vehicle the injured is occupying when the accident occurs or the vehicle that strikes the injured pedestrian or bicyclist covers medical expenses under PIP.
Second, if the vehicle identified above (First) does not have PIP coverage, any auto policy in which the injured is a named insured covers medical expenses under PIP.
Third, if neither of the first two scenarios listed above applies, the auto policy of anyone living in the injured’s household covers medical expenses under PIP
Fourth, if none of the first three scenarios listed above applies, the Massachusetts Assigned Claims Plan fund will cover medical expenses under PIP. Massachusetts General Laws Chapter 90, Section 34N
3. How much medical expenses coverage under PIP is available to the person injured in a Massachusetts accident?
If the injured person has a private, non ERISA health policy, the injured has at least $2,000 in medical expenses coverage under PIP, but no more than $8,000 in such coverage.
If the injured has no health policy, a non private health policy (i.e. Massachusetts Health) or an ERISA health policy, the injured has up to $8,000 in medical expenses coverage available under PIP.
4. What medical expenses will the PIP insurer cover?
The PIP insurer will cover the injured’s medical expenses if such expenses are (i) reasonable, and (ii) necessary and (iii) causally related to the insured accident, and (iv) incurred within two years of the insured accident
5. How long will PIP insurer take before it pays accident-related medical expenses?
If the person injured in a Massachusetts automobile accident incurs accident-related medical bills, the PIP insurer will pay covered medical expenses within a reasonable time – usually thirty (30) days.
The PIP insurer should pay medical expenses only after it obtains sufficient supporting documentation to assess the reasonableness or necessity of claims presented including reports from an independent medical examiner, if requested.
If the injured person’s accident occurred outside Massachusetts and the injured person files a lawsuit, the PIP insurer must pay covered medical expenses on or before the time of settlement or judgment.
If the injured person’s accident occurred outside Massachusetts and the injured person does not file a lawsuit, the PIP insurer must pay covered medical expenses within a reasonable time – usually thirty (30) days.
6. When will the PIP insurer NOT pay for an injured person’s accident-related medical expenses?
The PIP insurer will NOT pay accident-related medical expenses for it’s injured insured, who:
(i) occupied a motorcycle, motor vehicle not subject to motor vehicle registration, or a motorized bicycle;
(ii) contributed to own injury by operating under the influence, or
(iii) contributed to own injury by committing a felony or seeking to avoid arrest, or
(iv) contributed to own injury by intending to injure self or others; or
(v) injured self in the course of employment and entitled to worker’s compensation; or
(vi) causes insurer to deny claim for violation of the PIP policy’s cooperation clause, or
(vii) s/he or “household member” elected a deductible under the relevnt PIP policy, or
(viii) already recovered such medical expenses from settlement or court judgment, or
(ix) has received duplicate payments under another no-fault policy.
7. Even if the person injured in a Massachusetts automobile accident has a private health insurance policy, when will the relevant PIP insurer pay more than $2,000 in medical expenses?
In general, the relevant PIP insurer will pay more than $2,000 in accident-related medical expenses if:
(i) the relevant health insurance policy does not offer coverage for needed medical expenses. Any needed medical expenses for which the health insurer does not offer coverage shall be payable by the PIP insurer up to $8,000 in aggregate PIP coverage; or
(ii) the relevant health insurance policy has a deductible. Such accident-related medical expenses not covered by the health insurance deductible, shall be payable by the PIP insurer up to $8,000 in aggregate PIP coverage; or
(iii) the relevant health insurance policy has co-pays. Any co-pays for accident-related medical expenses shall be payable by the PIP insurer up to $8,000 in aggregate PIP coverage; or
(iv) the relevant health insurance policy limits needed treatments to a fixed number. Anything above that fixed number will be covered by PIP up to $8,000 in aggregate PIP coverage.
8. When the person injured in a Massachusetts automobile accident has private health insurance, when can the relevant PIP insurer refuse to pay accident-related medical expenses exceeding $2,000?
In general, the relevant PIP insurer can refuse to pay the injured person’s accident-related medical expenses if such person has private health insurance and:
(i) the injured person seeks out-of-network accident-related medical treatment under the relevant health insurance plan. For example, if the private health insurance plan requires that the injured person seeks treatment only from approved medical providers and the injured person seeks treatment from a provider not approved under the health plan, the relevant PIP insurer can refuse to pay for those unapproved services exceeding $2,000. or
(ii) the treating provider seeks to balance bill the health insurer’s allowed adjustments. For example, if the treating provider has contractually agreed to accept an adjusted amount from the injured person’s health insurer, such treating provider cannot bill the patient or the PIP insurer for the difference between the billed amount of such service and the contractual payment by the health insurer.
9. Can a person injured in a Massachusetts automobile accident ignore PIP and recover payment of all the needed accident-related medical expenses against the settlement of the party legally-responsible for causing the accident?
In general, No! When a person incurs accident-related medical expenses resulting from a Massachusetts automobile accident, that injured person may have the right to recover further damages from the party (or its insurer) legally responsible for causing such accident. According to the Massachusetts General Laws Chapter 90, Section 34M, however, such legally responsible party (or its insurer) is exempt from liability to the extent of PIP benefits paid or payable. Accordingly, the injured person must also recover from any relevant PIP insurance, if available.
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