By Richard Rizk
Most health insurance policies exclude treatment for injuries caused by someone else’s mistake. To fill that gap, Oregon requires all auto insurers to include a coverage commonly known as Personal Injury Protection (PIP), which pays “reasonable and necessary” medical expenses substantially caused by a motor vehicle accident for up to two years after the accident. This PIP medical benefit is payable regardless of fault. In other words, even if the accident was your fault, if your auto policy was issued in Oregon you have a way to pay some medical costs.
This is great news for folks who purchased auto insurance in Oregon. You also may make a claim for PIP medical benefits if you were a passenger in a car insured under an Oregon policy. Additionally, if you were a pedestrian injured by a motorist who has PIP coverage, and you are without other insurance that would pay medical costs, these benefits may apply.
But there is a catch. Oregon only requires $15,000 in PIP coverage (although many people purchase higher limits), which is often not enough to fully cover medical costs. To complicate matters further, many auto insurers balk at paying full PIP benefits by arguing that the medical treatment in question is not “reasonable and necessary”.
To generate medical evidence to support denial of PIP medical benefits, the auto insurer providing PIP benefits may require your attendance at a so called “independent medical exam” or IME. Make no mistake, these exams are not for medical treatment and are rarely independent. I refer to independent medical exams as what they really are, a defense medical exam.
Trap #1
If you attend the defense medical exam, you risk helping create an unfavorable medical report that can later be used against you by the insurance company for the at-fault driver. On the other hand, if you decide not to attend the exam, your own insurer will most likely balk at paying any further bills as you have a general duty to cooperate with your own insurance company.
Answer
Determining the best way to resolve this dilemma will depend upon several factors including:
- Future treatment you need
- The availability of other medical insurance to pay for your bills
- The willingness of your best doctors to go to bat for you
Sometimes it may make sense not to attend the defense medical exam to prevent the possible creation of unfavorable medical evidence. In other situations, such as when PIP limits are high and injuries are not likely to be contested, it may make more sense to attend a medical exam requested by the PIP carrier.
Trap #2
You have a lingering injury. You dutifully attend chiropractic care (or physical therapy), acupuncture and massage, paying with your PIP claim number. You really like your therapists, and these therapies ease your pain and improve your range of motion, but only temporarily.
Eventually these therapies become less effective and your pain increases. Concerned, you ask about the possibility of an MRI to rule out any need for surgery. Soon you discover that you have used up most or all available PIP medical benefits.
Answer
As soon as you realize that a treatment is not effective, seek a referral to the appropriate medical specialist. Often this means asking a primary care medical doctor for a referral to an orthopedic surgeon or neurosurgeon. A medical doctor who knows you and is familiar with your injury will be in the best position to suggest an appropriate medical specialist for your situation. Medical benefits under PIP coverage are limited to the policy limits purchased. Use that coverage wisely for tests and treatments designed to get to the heart of the injury rather than for therapies with a short-lived benefit.
