PIP Medical Benefits

1) What do PIP medical benefits cover?

The insurance provider of PIP benefits (usually your insurer) is required to pay reasonable and necessary medical expenses caused by a covered accident.

2) How do I start Oregon PIP medical benefits?

Call your auto insurer. Ask to open a “PIP” claim and provide requested information without giving a recorded statement (unless required by the policy). If a passenger, contact the auto insurer for the driver of the vehicle you were in to set up a PIP claim.

TIP: You have a duty to cooperate with the insurer providing PIP benefits (usually your or the driver’s insurer). The PIP insurer will require medical records that substantiate your need for treatment due to the accident. You should sign and provide HIPPA compliant medical release to the PIP carrier if requested. The PIP carrier will need it to access the medical records it needs to process your claim.

3) Should I give a recorded statement to an auto insurer?

Avoid giving any recorded statements to any insurance company. If your policy requires a recorded statement, consider hiring a lawyer for guidance. Prior statements may be used against you down the road. Never, ever give a recorded statement to the opposing insurer. Adjusters are trained to ask questions specifically designed to box in and limit claims.

4) When do Oregon PIP benefits expire?

The insurance provider of PIP benefits (usually your insurer) is required to pay reasonable and necessary medical expenses caused by a covered accident.

TIP: Always get written authorization from a treating M.D. for any therapy you need. Such authorization will help prove medical necessity.

5) After Oregon PIP benefits end, who pays MVA medical bills?

Once PIP benefits exhaust or expire, traffic accident medical bills may be processed through health insurance. To trigger health insurance company payment, fax or email the termination letter you received from the PIP carrier to the health insurer with cover letter asking them pay remaining medical bills from the accident.

Health insurance is not designed to pay medical care caused by a third person’s fault. Most health insurance policies contain language excluding such claims.

Expect the health insurer to eventually seek reimbursement for auto accident medicals it pays. The right lawyer will attempt to negotiate medical lien reductions with the health insurers and medical providers.

TIP: Before PIP benefits expire, request your complete health insurance policy. Review policy terms regarding the health insurers’ reimbursement rights.

TIP: Your health insurers may ask you to sign a “reimbursement agreement” before agreeing to pay medical providers who treat accident injuries. Consult a lawyer before signing any such agreement. Health insurance rights and duties should already be set out in the health insurance policy. However, a health insurer may refuse to process medical bills without a signed agreement to reimburse them.

TIP: Many health insurance policies are subject to deductibles and co-pay. Keep receipts and other evidence of out of pocket expenses. You will need for your claim with the “at- fault” insurance company.

6) Why did my PIP insurer sent me a letter agreeing to arbitrate?

An “agreement to arbitrate” letter from a PIP insurer is its attempt at avoiding attorney fees. While overturning a claim denial justifies an attorney fee under ORS 742.561, no attorney fee is available if the insurer agrees to arbitration and agrees the amount of a bill is the only issue. ORS 742.520 (6). Disputes about the amount of PIP benefits due are subject to arbitration. Id.

7) Why did the PIP carrier deny medical charge(s)?

The denial should explain why. Oregon insurers must provide written notice of the denial within 60 days of receipt and inform the insured of the reasons for the denial and method for contesting the denial. ORS 742.528.

TIP: If the denial stems from a clerical matter such as using an outdated medical code, for example, ask the medical provider to resubmit with proper coding.

TIP: If a denial cites a medical opinion, get an opinion of your own. Set an appointment with your most trusted treating physician. If the physician supports compensability, request an explanation in chart notes. The most persuasive opinions are well reasoned and supported by objective evidence (such as testing results)

TIP: Consider hiring a lawyer to pursue the insurance company for any denied benefits, attorney fees and costs. Under Oregon caselaw, PIP carriers who wrongfully deny risk paying the injured person’s attorney fees. See, Gaucin v. Farmers.

8) I have PIP coverage, but the owners of the vehicle involved were uninsured. Should I make a claim for PIP benefits on my auto policy?

Yes. Promptly notify your own insurer of the loss and the lack of coverage for the car you were in and ask your insurer to set up a PIP claim. Use the PIP claim number to bill medical treatment related to the crash.

9) My medical provider wants me to sign a letter of protection. What is that and what should I do?

A letter of protection is designed to guarantee a medical provider’s payment. Discuss your claim with a lawyer before signing such a letter. Not all protection letters are the same. Before signing one, ask a lawyer to assess whether there will likely be enough settlement /suit proceeds to pay all medical providers and other creditors.