No Fault Coverage is called “PIP”
In Oregon, your auto insurance company is required to pay medical bills and certain other living expenses, such as ongoing lost wages, medication, and in home assistance care while you are recovering from a motor vehicle accident. This “no-fault” coverage is known as Personal Injury Protection or “PIP”. PIP coverage is automatically included in every auto insurance policy issued in Oregon. Its purpose is to ensure that a minimum level of medical and other essential benefits are received by car accident victims, regardless of fault.
Do not Panic if PIP Denies
An Oregon case known as Gaucin v. Farmers provides a basis for attorney fees and costs if a court finds that the PIP insurer has wrongfully denied a medical bill or wage loss payment. Often a letter from an attorney is enough to persuade the PIP carrier to reconsider the bill. Sometimes the PIP carrier must be sued. Because of the risk of paying attorney fees, most insurers eventually decide to pay disputed amounts when pressured by suit.
Suing PIP Carriers: The Benefit at Trial
Car accident litigation is a charade in that all evidence of insurance is forbidden—even though insurance companies usually pay car crash losses. Why? Insurance company lobbyists have convinced Oregon lawmakers that juries will award too much if they know an insurer, not the bad driver will pay the loss.
Strange as it sounds, a PIP carrier who wrongfully denies can actually help an injured person at trial by shattering the illusion that insurance is not involved. A case about an insurance company who does not want to pay usually has more punch than a case about a driver who made an error operating a vehicle. Jurors can easily deduce that just as the injured party has PIP insurance, so probably does the driver at fault. To some extent insurance company lobbyists are right, most jurors do hate insurers.
Return & Complete the PIP Application
Most insurers require their insured’s to complete a written or telephonic PIP application form in order to obtain PIP benefits. Complete this form as soon as possible. Your insurer needs to know about your injury from the accident and who you are treating with in order to process you medical bills and wage loss claim.
Provide Medical Release to PIP Carrier, not Liability Carrier
Also, because of a medical records privacy law known as HIPPA, your PIP insurer will ask for a medical release so it can obtain your medical records. Generally speaking, you should provide your PIP carrier with this release. Most auto insurance policies require their insureds to “cooperate” with their investigations. As a practical matter, you probably won’t get PIP benefits paid without providing the requested release. If your insurer is also the insurer for the bad driver, be sure you know which adjuster you are talking to. DO NOT SEND A MEDICAL RELEASE TO THE INSURER FOR THE PARTY AT FAULT. Doing so only gives the opposing insurance company a head start in in its effort to oppose your claim.
Minimum Required “PIP” Benefits in Oregon
The minimum PIP coverage required by Oregon law is:
- $15,000 for up to two years of “reasonable and necessary” medical expenses
- WAGE LOSS
- 70% of your pay, up to $3,000 per month for 52 weeks when you have to take more than 14 days or more off work because of your accident
- CHILD CARE
- $25 per day up to $750 if you are hospitalized for at least 24 hours
- ESSENTIAL SERVICES
- $30 per day for up to 52 weeks if you do not work and need help with, e.g., cooking and cleaning
- FUNERAL EXPENSES
- $5,000 within one year
Money paid for “reasonable and necessary” medical treatment and other loss, child care and funeral expenses under the PIP coverage of your auto policy is usually eventually reimbursed to your insurer by the insurer for the driver at fault.
Repayment of PIP Benefits in Oregon
Since 2016 Oregon follows “make whole rule”. Under the “PIP make whole” rule the injured person must be “made whole” before PIP gets paid back. In other words, the insurer providing PIP benefits gets repaid only AFTER ALL OF THE INJURED PERSON’S damages are paid— both economic ($) and non-economic (pain & suffering) is defied and paid.
To qualify for PIP reimbursement from the insurer for the party at fault, the auto insurer providing PIP benefits (your insurer if you were the driver) must elect to assert a “lien”. A lien is asserted when the PIP adjuster believes the bad driver’s insurance limits will not be sufficient to cover your claim and PIP amounts.
Most PIP insurers do not elect to assert a lien because doing so will obligate the PIP insurer to pay its fair share of attorney fees and costs. As a result, most PIP insurers decide to try to recoup directly from the insurer at fault without attorney involvement.
PIP Pays “Reasonable and Necessary” Medical Care
Your Oregon no fault PIP insurance carrier is required to pay “reasonable and necessary” medical expenses related, to the accident, up to your policy limit (usually $15,000). PIP benefits expire one year after the accident.
The PIP “Independent” Medical Exam” (IME)
Your insurance company would rather not pay all PIP benefits up to your policy limit. PIP insurers refer to ‘bell charts’ showing when the average person with your type injury should be finished treatment. When your treatment is beyond the median level of treatment, the PIP adjuster is prompted to evaluate whether treatment remains appropriate. To get evidence it needs to deny medical service, the insurer providing PIP benefits may ask you to be evaluated by a so-called “Independent Medical Examination and Evaluation.” Insurance company doctors are rarely impartial or independent. Most insurer-hired physicians predictably opine that future treatment is not necessary. If you are scheduled for an IME discuss with your attorney the following strategies: 1. Not attending IME; 2. Primary Care Physician post IME visit; or, 3. Make a deal with PIP carrier;
Not Attending the PIP IME
The PIP carrier may deny remaining PIP benefits even if you do attend IME.
If you have good medical insurance, NOT attending an IME may make sense. IMEs usually do not favor an injured person. The PIP carrier may share the IME result with the insurer for the bad driver. The only way to make sure your own insurer (the PIP carrier) does not generate evidence to undermine your claim is not to attend the IME.
If you do not attend the IME the PIP carrier will surely deny remaining PIP benefits. Depending on the circumstances,
Who Gets Oregon PIP Benefits?
- Driver – The driver’ own insurance company pays the driver PIP benefits ;
- Passengers – The driver’ own insurance company pays the driver PIP benefits; When the driver’s PIP benefits are exhausted, the passenger may then tap PIP coverage under her own policy if still within the first year after the accident.
- Pedestrians: The driver of the vehicle striking a pedestrian pays the injured pedestrian’s PIP benefits;
- Bicyclists: The driver of the vehicle striking a bicyclist pays the injured bicyclist’s PIP benefits; Entitlement to PIP benefits may hinge on specific facts of each case.
Oregon PIP Carrier Denial
Contrary to one well known insurer’s jingle… PIP insurers are not on your side. Your insurance company will be looking to end PIP payments as soon as it can justify doing so. The three most common reasons Oregon PIP cite to justify a denial of medical benefits are: 1. The treatment is not reasonable & necessary; 2. The treatment is not related to the crash; and, 3. PIP benefits are expired or exhausted.
NOT Reasonable and Necessary
To minimize chances that your PIP insurer will claim that PIP benefits are not reasonable or necessary: ! Reconsider continuing treatment has not worked; ! Have an up to date referral from an M.D. for all therapies; ! Do not solely treat with a Chiropractor; ! Do not miss scheduled visits without reason; and, ! Avoid lapses in treatment;
NOT Related to the Crash
PIP insurers commonly point to other causes for your need for treatment including: ! Prior injury; ! Pre-existing degenerative disc disease; ! Idiopathic causes (“a disease or condition of unknown cause or which arises spontaneously”) ! Subsequent Injury;
Pre-existing Degenerative Disc Disease
In the context of traffic accidents, “pre-existing degenerative disc disease” is among the most common of all defenses because nearly every adult has some level of spinal degeneration– which can be easily verified by diagnostic tools. However, the mere presence of degenerative disc disease does not establish a “cause-effect” relationship between “degenerative disc disease” and a need for treatment. Frequently, degenerative disc disease existed but was asymptomatic until the crash. In these cases, expert medical evidence may be needed to prove the relationship between the collision and a need for treatment.
Other Injuries as Cause
Other injuries are also frequently alleged as the cause of your need for medical treatment. If this occurs, the best antidote is often films (X-rays, CT scan or MRI) taken before and after each injury. Keep in mind, films might also undermine your claim. Similarly, imaging of the wrong type or of the wrong area are susceptible to incorrect “normal” interpretations. Maximizing PIP benefits requires an understanding of what test to take when.