Resolution of PIP Claim Disputes in Motor Vehicle Accident Cases
By Richard H. Adler
November 13, 1997
When a person injured in a motor vehicle accident has a conflict with his or her automobile insurance company, it often involves the insurer’s refusal to pay or delay in paying for medical expenses under the insured’s automobile Personal Injury Protection (PIP) policy. There are several options available for your patient to resolve this dispute, including arbitration under the terms of their PIP policy. Most PIP policies in Washington state provide for dispute resolution through arbitration.
It must be noted the option of resolving a dispute surrounding payment of an outstanding bill is only available to the insured and his or her attorney, not the health care provider. The insured has the contract with the insurer. The insured paid premiums to the insurer in exchange for a promise to cover medical expenses arising from a motor vehicle accident. If the insurer does not cover the bills, then the insured claims the insurer breached the terms of the insurance policy (contract). The health care provider may be an indirect beneficiary of the PIP policy, but has no legal right to challenge an insurer’s refusal to pay its bill. The action must come from the insured.
When a dispute arises in a PIP claim, most insurance policies have a provision similar to the following:
If we and a person seeking PIP Coverage do not agree on the amount payable under this coverage, the matter shall, upon mutual written agreement, be decided by arbitration.
Arbitration is a forum for resolving disputes that is intended to be less costly and time consuming than filing a lawsuit. Arbitrators are attorneys who have experience in hearing cases and deciding outcomes. In an arbitration, each side presents its evidence to the arbitrator(s) who then decide the claim. Most arbitration decisions are “binding”, which means that both parties must abide by the arbitrator’s decision and the matter is considered closed. No appeal is possible.
PIP policies usually specify whether an arbitration will be heard by a single arbitrator or by a panel of three arbitrators. If the parties agree on a specific arbitrator, that person will hear and decide the matter. If the injured person and the insurance company cannot agree, each party will choose an arbitrator and the two will choose a third. A decision is made based on the agreement of two of the arbitrators.
Choosing an arbitrator is an important part of the PIP dispute resolution process. Arbitrators have differing professional backgrounds and experiences. There are many arbitration services which can provide a list of available arbitrators to choose from. An attorney handling a PIP arbitration will choose the arbitrator he or she knows from experience will understand the issues presented.
Once the arbitrators are chosen, a hearing is scheduled. Evidence is prepared for presentation and any witnesses the attorney intends to call are scheduled.
A brief letter to the arbitrator(s) is prepared and a complete copy of the documentation is mailed several days prior to the hearing. If live witnesses will be called at the hearing, the arbitrator(s) is advised. This evidence will generally consist of health care records, bill, reports, and the patient’s testimony.
If there are questions that are not clearly addressed in the records, the treating doctor may be asked to answer specific questions in writing or live through testimony at the hearing. This provides the patient and attorney with the advantage of having the expert there to address unexpected questions that may arise. The evidence is presented to show the treatment the patient received was as a result of the accident and that it was “reasonable and necessary”, as well as related to the collision. Simply put, this means the disputed care was necessitated by the auto accident and has helped him or her get well by reducing pain and increasing function with regular daily activities (work, recreation, family).
At the hearing, each party presents his or her side of the issue utilizing the documentation to support the case. Though emotionally charged pleas for justice may get results in the movies, this strategy may provide disappointing results in a real PIP arbitration. Testimony of all witnesses, including the patient, need to be presented in a calm and concise manner. Following the hearing, the arbitrator(s) will advise the parties of the decision within several days.
We hope this article provides you and your staff with an overview of one option available to your patient (and his or her attorney) when insurers refuse or delay payments for treatment provided under the PIP policy. Please feel free to call the attorneys at Adler Giersch PS for assistance to you or your patient concerning a personal injury claim. We have offices conveniently located in Seattle, Bellevue, Everett and Kent and are glad to help.