Oregon “PIP” Covers Medical Cost
Oregon lawmakers created an insurance scheme whereby motor vehicle accident (MVA) victims need not twist in the wind without medical care while trying to prove fault. To accomplish this, Oregon law requires that every Oregon personal auto insurance policy provide at least $15,000.00 of no fault “PIP (Personal Injury Protection) coverage for “reasonable and necessary” motor vehicle accident medical expenses. Ambulance, physician, hospital, medicine, medical supplies, psychiatric, imaging, lab tests, rehab, prostheses, nursing, dental, eye and chiropractic are examples of MVA related care covered by PIP coverage. The general rule is that PIP coverage follows the car. So if the car is insured, PIP covers the driver’s injuries and all occupants of the car, regardless of fault. Each passenger’s own auto PIP coverage would pick up when the driver’s PIP coverage exhausts or denied.
Oregon PIP medical coverage applies even if accident occurs outside Oregon–so long as the insurance policy was issued to an Oregon resident. Conversely, if the policy was issued to a resident of a state other than Oregon, that other state’s law applies even if the accident occurred in Oregon.
For example, if the accident occurs in Oregon but the insurance policy was issued to a Washington resident, Washington law would apply as to insurance issues while the claim against the bad driver would be governed by Oregon law. Unlike Oregon, Washington allows but does not require no fault PIP coverage. Insurance coverage issues are always controlled by the laws of the state where the policy was issued. Jurisdiction for the injury case can be either the state where the accident occurred or the state where defendant (bad driver) resides.
Reasonable and Necessary
PIP covers “reasonable and necessary “medical expenses caused by the crash. Most auto carriers question treatment for soft tissue injuries beyond 4 months without objective evidence of injury (ex: X-ray, MRI, CT scan), a persuasive medical opinion or evidence of severe impact.
TIP: Auto insurers are generally biased against alternative care. See a M. D. early on request appropriate testing or referral to a specialist to substantiate harm and rule out serious injury.
Undertreating & Overtreating
Aim for just the right amount of treatment—No more and no less than you need. Treating with the wrong provider wastes precious PIP coverage. Do not to burn PIP coverage on alternative care if you suspect a more serious (and expensive) injury. Remember, unlike most health insurance policies, Oregon PIP coverage is not subject to deductibles or copays. And, PIP coverage will eventually expire. Use PIP coverage, but be careful not to over treat to avoid getting stuck with medicals bill denied by insurance.
TIP: Think of your PIP claim number a currency for medical treatment. Provide it to all providers who treat your traffic accident injuries.
TIP: Frequently undertreated potentially serious conditions include traumatic brain injury (TBI), post-traumatic stress disorder (PTSD) and neurological damage (numbness and tingling in extremities, persisting headaches can be signs of neurological damage). Seek appropriate medically trained specialists early on if you suspect a serious condition.
Finding Medical Care
Some medical providers do not accept motor vehicle accident (MVA) patients. This is probably because Oregon medical providers are paid less to treat MVA injuries. Oregon law requires motor vehicle injury medical providers accept the lesser of:
The reduced schedule of medical fees under ORS 656.248; or The provider’s usual charge to the public. See ORS 747.525.
TIP: Establish a relationship with a primary care physician prior to a motor vehicle accident. That way it should be easier to get referrals and tests you need.
Oregon “PIP” Medical Summarized
Oregon requires all policies issued within the state to provide at least $15k of medical coverage (PIP) for injuries caused by a motor accident regardless who is at fault. Even if Oregon policy does not, on its face, provide any PIP coverage, you get $15k PIP coverage as a matter of law because Oregon law requires every policy issued in Oregon to provide at least $15k of PIP coverage. ORS 742.450; See Viking Ins. Co. v. Petersen, 308 Or. 616, [312 Or. 341] 621, 784 P.2d 437 (1989); See also, Collins v. Farmers Ins. Co. of Oregon, 312 Or. 337, 822 P.2d 1146 (1991). Insurance companies may not issue auto policies in Oregon providing less than state minimum limits. Id.
If you were the driver, your own insurance company will pay reasonable and necessary medical charges up to the amount of PIP coverage you purchased but at least $15k. If you were a passenger, the driver’s PIP coverage is primary. If the primary PIP policy is not enough to cover the reasonable and necessary medical bills, you can then tap PIP coverage under another auto insurance policy. In other words, in Oregon you can “stack” PIP coverages of different policies.
If the primary PIP policy is not enough to cover the reasonable and necessary medical bills, you can then tap PIP coverage under another auto insurance policy. In other words, in Oregon you can “stack” PIP coverages of different policies.
Ever since Congress passed the McCarran-Ferguson Act in 1945, regulation of insurance has been largely a state matter. Of western states only Oregon and Utah require PIP no fault medical coverage. So, if your policy was issued in another state, request a copy of your policy declarations page to check whether and to what extent you have PIP coverage.
Some states that do not require PIP coverage offer a no fault medical payment insurance known as Medical Payments or “Med Pay”. Med Pay is akin to PIP, but much less comprehensive and usually provides lower limits.
Depending on the law of the state where the policy was issued, Med Pay can be primary or secondary to your health insurance. If Med Pay is supplemental, your health insurer initially pays with Med Pay contributing toward health insurance deductibles and co-pays. If it is primary, Med Pay pays covers initial medical costs then health coverage kicks in for any excess. Med Pay applies whether you are injured as a passenger, while on public transportation, or if you’re hurt by another driver as a pedestrian or biking.
Private Health Insurance Policies
If you do not have PIP or Med Pay coverage but have health insurance, bill accident related medical charges to your health insurance company. Keep in mind, health insurance policies typically exclude accidents caused by a third party. In other words, your health insurer will eventually seek reimbursement for amounts it paid toward accident related treatment.
Medicare & Medicaid
If you are eligible to receive Medicare benefits federal law requires you to report injury accidents to the Medicare Coordination of Benefits Contractor. To identify the appropriate COB contractor, go to www.msprc.info or www.cms.gov. Inform the COB contractor of your medical providers, lawyer, insurers and claim numbers.
Medicaid benefits are typically administered through a state sponsored health insurance program. If you have no other health insurance, Medicaid will initially pay the medical bills. Surprisingly, when accident related health care costs are paid through Medicare or Medicare settlement is easier because health care charge less to Medicare patients and providers sometimes “write-off” chunks of bills realizing collection challenges.
OPPORTUNITY: Even though Medicare and Medicaid recipients usually not need to repay medical charges at 100%, billed, the party at fault must reimburse the entire bill from the party at fault. See, White v. Jubitz Corporation, 347 Or 212 (2009). The White opinion reasons that the injured person, not bad actor should benefit from any medical charge fee reduction. Id.
TRAP: Federal law prohibits Medicare and Medicaid eligible persons from resolving personal injury claims without first receiving a “Conditional payment letter” setting out the amount Medicare or Medicare must be repaid from settlement or verdict proceeds.
TIP: To find out how much Medicare has paid toward your injury claim, create a user id and log into Medicare at https://www.mymedicare.gov/. Don’t even think about not reporting the accident to the COB contractor. They have ways of finding out. Failure to report an accident to Medicare will jeopardize your benefits.