The Personal Injury Protection Guide for Providers
By Lauren E. Adler
June 28, 2017
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.