The Personal Injury Protection Guide for Providers

PIP

By Lauren E. Adler, Attorney at Law

If your patient is treating from a car collision, Personal Injury Protection Insurance (also known as PIP) is one way that your services are paid for.  We advise providers and patients alike to double check—and then triple check—that PIP is listed on the declaration page of their auto insurance policy.  If you don’t have it, add it.

PIP is great because it covers medical treatment more broadly than many health insurance policies.  To the extent of your patient’s PIP limits of at least $10,000 (the mandatory minimum that auto insurers in Washington must offer), there are fewer restrictions on what is covered, no in-network/out-of-network distinction between providers, no copays, no deductibles, and no annual visit limitations.  According to the Revised Code of Washington (RCW) 48.30.010 and the Washington Administrative Code (WAC) 284-30-395, the statute and rule which establish the legal standards for prompt, fair and equitable settlements by insurance companies for PIP claims, a bill submitted under PIP can only be denied if the treatment (1) is not reasonable, (2) is not necessary, (3) is not related to the collision, or (4) occurs after 3 years of the collision date.  WAC 284-30-395 provides, “These are the only grounds for denial, limitation, or termination of medical and hospital services,” under PIP.

PIP covers any person named on the auto policy, as well as household members.  Any passenger in the insured car is covered, as well as any pedestrian or cyclist involved in the collision.  Furthermore, a patient is not limited one layer of PIP coverage. If the patient has their own auto policy, that PIP comes in as a secondary layer.  Depending on the situation, there could be multiple layers of PIP available, depending on the patient’s own policy and their role in the collision – owner, driver, passenger, pedestrian or cyclist.  If you are unsure about a patient’s potential PIP coverages, we recommend the patient consult with an attorney.

If your patient is treating from a collision caused by someone else, save yourself the energy of sending bills to the at-fault driver’s insurance company.  The at-fault insurer is not responsible for a dime until the patient’s injury claim is ready for settlement.  PIP, on the other hand, pays medical bills on an ongoing basis.  So even if your patient is not at fault and it seems counterintuitive to send the bills to the patient’s own insurance company, all bills go to PIP.  When PIP runs out, the patient’s health insurance is next in line to pay.

All of this may sound well and good, but it often isn’t smooth PIP sailing.  Insurers are always cooking up creative ways to deny bills and to discourage drivers from obtaining, or increasing, PIP coverage.  While Washington state law requires insurers to offer PIP insurance, insurers make it very easy for drivers to “waive” their right to PIP by simply clicking a “rejected” box on the insurance application.

Below, we happily debunk some of the myths insurers would love you or your patients to believe about PIP.

  1. If you have health insurance, you don’t need PIP.

False.   PIP is not extraneous – it is protective.  As long as treatment is reasonable, necessary, and related to the collision, PIP must pay for the care.  Therapy visits are not limited per the terms of a PIP policy like they frequently are in health insurance policies.  Because PIP is more expansive in terms of medical treatment covered, often times it is absolutely necessary to have, especially for patients who could not otherwise afford to pay out of pocket for treatment that goes beyond their health insurance allowance.   Moreover, PIP insurance covers wage loss and household services expenses the patient may incur as a result of the collision.

  1. The adjuster is the final authority on whether your patient has PIP coverage available to them.

False.  Just because the adjuster tells your patient there is no PIP coverage on his or her auto policy, that isn’t necessarily the final word.   Under Washington state law, insurance contracts are interpreted in favor of the insured, not the insurance company, so the insurer has the burden to prove that they offered PIP but the patient rejected it.  The rejection must be signed in writing by the patient, so the adjuster simply saying that there is no PIP available is not good enough.  Your patient should demand a copy of the signed waiver.  If the insurer cannot produce it, the adjuster must open a PIP claim for a minimum of $10,000.

  1. PIP does not cover “palliative” care.

False. Whether treatment is “palliative,” i.e., will not ultimately cure the patient, is not relevant.  Under the law, what matters is whether the treatment is (1) reasonable to address the injuries, (2) necessary to treat the injuries, and (3) related to the collision.  If it is all three, PIP is obligated to pay.  RCW 48.30.010; WAC 284-30-395.

  1. The patient must sign a release allowing the insurer unrestricted access to all medical records.

False. The patient does have a duty to cooperate with the PIP insurer, so they do need to allow the adjuster access to records for collision-treatment if it is requested.  However, the adjuster needs only enough to determine that treatment is reasonable, necessary, and related to the crash.  We recommend a careful review of any release your patient signs, especially if the patient has a long history of treatment, to ensure the insurer does not get full access to the patient’s entire history and file which could be used against them to cut off care.

  1. The adjuster can make their own medical determinations.

False.  Medical opinions, such as whether your patient’s injuries are from a prior condition, whether your patient is getting too much treatment, or whether your patient does not need further care, must be made by a medical practitioner.  If the adjuster decides to cut off your patient’s PIP, that decision must be supported with a medical opinion from a similarly licensed healthcare professional.  If the adjuster asks your patient for an exam, called an Insurance Medical Exam, is usually a sign that the insurer is gearing up to cut off your patient’s PIP.

  1. PIP coverage ends when the patient improves enough.

False.  PIP covers care until it is no longer reasonably necessary, or until coverage runs out. The insurer cannot close a PIP claim because a patient is able to go back to work, or is somewhat improved.

The attorney team at Adler Giersch is experienced at navigating PIP insurance issues. If your patient has been put on notice that they will need to attend an IME, or is getting the runaround from their PIP insurer, let us know and we are happy to advise.

 

The Emerging Privacy Invasion from the Insurance Industry

By Jacob W. Gent, Attorney at Law

The auto insurance industry have begun implementing programs to provide more personalized quotes based on the actual driving habits of consumers through the use of auto tracking devices.  And some insurance companies are offering consumers financial incentives in the form of discounts, as much as 30% off premiums, to entice customers to install these tracking devices on their vehicles.[1]  Before deciding to enroll in such a monitoring program, one should stop and consider the motivation and risk behind these offers.

The birth of tracking devices is the offspring of “telematics,” the merger of telecommunications and infomatics, enabling the insurance industry to move closer to a “Pay How You Drive” business model that can calculate premiums based the driving habits of the policyholder.[2]  These devices are installed in your car and records information such as vehicle speed, acceleration and braking rates, cornering, miles driven, vehicle location and route driven, time of day the vehicle is driven, and other vehicle operational information such as fuel consumption.[3]  Telematic systems may be linked through your smart phone, connected to a vehicle’s infotainment system, or plugged in to the On-Board Diagnostics (OBD) port.

While the allure of cheaper rates for car insurance is appealing, make no mistake: insurance companies are out to earn profits, huge profits.  No matter how neighborly, caring, or friendly their advertising scheme may be, auto insurers will be able to search the data collected through telematics to show you are a “risky driver” in order to raise your rates.  And with telematic tracking devices voluntarily installed in a customer’s vehicle, the easier it is for insurers to charge higher premiums.[4]

The criteria you must satisfy to receive any premium discount is determined exclusively by the insurance company and subject to change at any time.  Moreover, insurance companies do not guarantee any discount when you enroll in these monitoring programs.  According to Progressive’s Snapshot Common Questions FAQ:

“Most Snapshot customers earn a discount based on their safe driving; however, riskier driving based on [driving habits that] indicate a greater likelihood of being in an accident and may result in a higher rate at renewal.”[5]

This means that your premiums will be set based on a projection of a collision, not on data of an actual collision.  Progressive was the first auto insurer in the United States to start using a telematics tracking system.  Beginning in 1998, Progressive rolled-out the “Snapshot” program Copy of March 2017 Advocate Article to incentivize good driving habits by offering discounts to safe drivers.[6]  Initially, the data collected by Progressive was only used to determine whether a policyholder qualified for the advertised discounts.  But starting in 2013, Progressive began using telematics data to adjust and increase rates based on driving behavior.[7]

Progressive claims 80% of its policyholders would benefit from the Snapshot program, but interestingly only about 25% of their customers participate in the program.  Similarly, Allstate reported to the Wall Street Journal that approximately 30% of its customers participated in its Drivewise program.[8]  Apparently, not all drivers are eager to give insurance companies access to more of their personal information, such as where they drive and when.

The reluctance of many consumers to sign on to these insurance industry programs has something to do with well-founded privacy concerns.  Advertisers, and the data brokers who sell information to them, track consumers’ virtual footprints online while banks and credit card companies track when and where customers shop, and retailers monitor and market to consumer buying patterns.[9]  Monitoring when and where a person drives can feel especially intrusive to the American consumer, where the idea of the “open road” is synonymous with our general notion of freedom.

Even more concerning is the question of who else might gain access to this information.   According to Jeff Wright, Vice President of Usage Based Insurance at Liberty Mutual:

“Liberty Mutual values and respects our customers’ privacy.  We will not share personally identifiable usage data we collection with any third party except to service our customers’ auto policies, for research, or as required by law.”[10]

The assurance of protecting privacy in the first part of the sentence is voided by the phrase “except to service our customers’ auto policies, for research, or as required by law.”  That latter statement is vague enough to allow insurers to do what they want with the data.  For example, the phrase “required by law” means your personal data could be subject to subpoena by a court or provided to law enforcement agencies to comply with state or Federal laws, which may have nothing to do with an individual’s driving habits.[11]

Many theorize that it is only a matter of time before insurance companies require telematics devices be used on every vehicle before issuing a policy and that certainly appears to be the trend within the automobile manufacturing industry.  According to a white paper by IHS Technology published in 2011, it is predicted that “by the end of 2018, the percentage of new cars available for sale in the U.S. Market with embedded telematics will soar to 80 percent.”  A 2013 report by ABI Research stated “global insurance telematics subscriptions [are predicted] to grow at a compound annual rate of 81 percent from 5.5 million at the end of 2013 to 107 million in 2018.”[12]  Once the use of these tracking devices becomes mandatory, insurance companies’ profits will soar as they constantly monitor their customers’ behavior.  Until that time, be sure to read the fine print before voluntarily agreeing to participate in any insurance monitoring program to decide whether the possible savings is worth the privacy you are giving away.

Next time you think, “Why not? It may save me a few bucks…,” stop and consider the motivation and risk behind the offer.  The attorneys at Adler Giersch are as committed to advocacy for our clients as we are on staying abreast of developments in the insurance, legal, and medical worlds that impact all of us.


[1] Consumerist; https://consumerist.com/2016/01/11/some-drivers-dont-want-insurance-companies-tracking-them-even-if-it-means-discounts/

[2] Digital Trends; https://www.digitaltrends.com/cars/how-telematics-may-affect-your-auto-insurance-rates/

[3] Allstate.com; https://www.allstate.com/tools-and-resources/car-insurance/telematics-device.aspx

[4] Digital Trends.

[5] Progressive.com; https://www.progressive.com/auto/snapshot-common-questions/

[6] US News & World Report; https://cars.usnews.com/cars-trucks/best-cars-blog/2016/10/how-do-those-car-insurance-tracking-devices-work

[7] Id.

[8] Consumerist.

[9]  Id.

[10] Digital Trends.

[11] Id.

[12] Digital Trends.