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ACCIDENT VICTIMS RIGHTS REQUIRING INSURANCE TO PAY FOR MEDICAL/ CHIROPRACTIC TREATMENT
If injured in a car accident, it is important to immediately seek hospital and medical or chiropractic treatment. Under the New Jersey No Fault Act, car insurance companies are supposed to make timely payment of medical bills for the driver and passengers injured in their cars or other non-commercial vehicles. Doctors should let their patients know there are now minimum deductibles under the NJ Car No Fault Law (PIP). The following is helpful information for injured people and their doctors to obtain payment for bills.
1 Bills should be submitted to PIP & also to Major Medical and to Patient The medical provider must first submit the unpaid bills to the patient's car insurance carrier Personal Injury Protection (PIP carrier), and/or any Blue Cross/Blue Shield or other related medical provider, and fill out any documents required by the insurance company.
2. Deductibles There is an initial $250.00 deductible, and thereafter the car insurance company pays 80% of medical bills under a medical fee schedule established by the State Dept. of Insurance. After $5,000 the car insurance company pays 100% under the fee schedule, unless an independent medical exam (IME) recommends no further treatment. We recommend doctors adequately notify patients that they are the primary responsible person for payment, not insurance companies. They are also called the PIP (Personal Injury Protection) benefits under the No Fault Law. For unpaid portions after 80% or under the deductible, the chiropractor and also patient should submit portions of bills the car insurance does not pay to their major medical carrier (ex- Blue Cross, Connecticut General). Patients must be told that if they have the lawsuit/ verbal threshold, they cannot even sue the negligent driver for their unpaid medical bills.
3. 21 day notification to PIP A State Law signed in January, 1996 requires automobile insurers to be notified by the claimant or medical provider in writing within 21 days following commencement of treatment of injuries sustained in an accident for which personal injury protection medical expense benefits are claimed. NJSA 39:6A-5(b) In addition, under this new law P.L. 1995, c 407, every bill for such treatment shall be submitted to the insurer and submitted by the medical provider if within 30 days of the date that treatment was rendered. N.J.S.A. 39:6A-5E (a) If the treating doctor does not give proper notification, the insurer can reserve the right to deny payment of the claim, and the treatment provider is prohibited from seeking a payment directly from the insured NJSA 39:6A-5(d) New Jersey Auto Insurance Law p 157 (GANN 2000). It is highly recommended that all doctors, hospitals, MRI facilities and physical therapy centers also send complete copies of all bills to the patient. Unfortunately, too often doctors or MRI facilities fail to advise patients of high unpaid bills, then put the patient in collection after the case is over for the unpaid bill.
Patients should submit copies of all bills to your car insurance company even if they believe the doctor or medical providers may also have submitted the bill to PIP. The patient should later send the bill to major medical. If the doctor's office and injured person does not keep their attorney's office informed in writing of unpaid medical bills, the attorney will not have sufficient information to provide to the defendant's insurance company and the Court when trying to settle a case.
4. New Care paths in Car Accident Cases Starting in 1999, all medical providers must follow "care paths" and most non emergency treatment approved by the car insurance company. Please make sure all treatment and bills are pre- approved by the car insurance company. The treating doctor should also contact the car insurance company prior to MRI or extensive treatment.
5. Dispute Resolution to require Payment of Doctor and MRI Bills following a car accident The intent of the no fault statute is to require speedy payment of hospital and doctor bills and prevent delay by insurance companies. An aggrieved personal injury protection claimant is entitled to receive "prompt payment of medical expenses, lost wages, essential services, survivor benefits and funeral expenses... without having to wait the outcome of protracted litigation." Kubiak v. Allstate Insurance Co., 198 N.J. Super. 115, 119 (App. Div. 1984), cert. den. 101 N.J. 290; Hoqlin v. Nationwide Mutual Insurance Co., 144 N.J. Super. 475, 479 (App. Div. 1976). This, together with the right to interest on overdue payments (then N.J.S.A. 39:6A 5(c)) and the ability under Rule 4:42 9(a)(6) to recover counsel fees if successful in the action should sufficiently guard against situations where an injured party is subjected to protracted aggravated consequences because of an insurer's failure to pay. Kubiak 198 N.J. Super. 119 120.
Disputes between the insurer and claimant as to whether or not benefits are due under the PIP statute may be resolved, at the election of either the claimant or the insurer, either by binding arbitration or by civil litigation. NJSA 39:6A-5(i) and NJSA 39:6A-5.1a, New Jersey Auto Insurance Law p 159 (GANN 2000) If the insurance company continues to delay and fails to pay medical benefits, the insured can either file suit in the Superior Court or file a demand for dispute resolution with American Arbitration Association. In New Jersey their office is located 1 Executive Drive, Somerset, New Jersey 08873. Filing fees are $325, paid by either the doctor/treatment provider or the patient. The check should be payable to the American Arbitration Association.
5a. NJSA 39:6A-5.1 sets forth in detail how AAA dispute resolution proceeds Dispute resolution proceedings shall include disputes arising regarding medical expense benefits provided under PIP law and disputes as to additional first party coverage benefits required to be offered. Disputes involving medical expense benefits may include, but not necessarily be limited to, matters concerning (1) interpretation of the insurance contract; (2) whether the treatment or health care service which is the subject of the dispute resolution proceeding is in accordance with the provisions pip law or the terms of the policy; (3) the eligibility of the treatment or service for compensation; (4) the eligibility of the provider performing the treatment or service to be compensated under the terms of the policy or under regulations promulgated by the commissioner, including whether the person is licensed or certified to perform such treatment; (5) whether the disputed medical treatment was actually performed; (6) whether diagnostic tests performed in connection with the treatment are those recognized by the commissioner; (7) the necessity or appropriateness of consultations by other health are providers; (8) disputes involving application of and adherence to fee schedules promulgated by the commissioner; and (9) whether the treatment performed is reasonable, necessary, and compatible with the protocols provided for pursuant to P.L.1998, c.21 (C.39:6A-1.1 et al.).
The dispute resolution professionals may review the entire claims file of the insurer, subject to any confidentiality requirement established pursuant to State of federal law. All decisions of the dispute resolution professional shall be in writing, in a form prescribed by the commissioner, shall state the issues in dispute, the findings and conclusions on which the decision is based, and shall be signed by the dispute resolution professional. All decisions of a dispute resolution professional shall be binding. The dispute resolution organization shall provide for the retention of all documents used in dispute resolution proceedings under this section and section 25 of this amendatory and supplementary act, including the written decision for a period of at least five years, in a form provided by the commissioner, or such additional time as may be established by the commissioner. The written decisions of the dispute resolution professional shall be forwarded to the commissioner, who shall establish a record of the proceedings conducted under the dispute resolution procedure, which shall be accessible to the public and may be used as guidance in subsequent dispute resolution proceedings.
Under the pre-1999 no fault law, AAA arbitrations were heard by a single arbitrator chosen by AAA. The arbitrator would fix the time and place for each oral hearing. Persons having a direct interest in the arbitration are entitled to attend hearings. Parties may offer such evidence as is relevant and material and shall produce such additional evidence as the arbitrator may deem necessary to an understanding and determination of the dispute. The arbitrator may subpoena witnesses or documents on his own initiative or upon the request of any party. The arbitrator shall be the judge of the relevancy and the materiality of the evidence offered, and conforming to legal Rules of Evidence is not necessary. An arbitrator may receive and consider the evidence of witnesses by affidavit, but it shall give it only such weight as the arbitrator deems it entitled to after consideration of any objections made to its admission.
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