What is PIP in the Legal Sense?
Personal Injury Protection (PIP) is an optional coverage type that some insurance companies offer. PIP state laws vary from state to state. In most states it will cover any medical costs related to injuries sustained in an auto accident that the injured party is responsible for under the negligence rules. PIP may also include coverage for lost wages and sometimes household help coverage for people that are too injured to perform housework chores. If you reside in a no-fault or PIP state , then PIP will be the primary coverage for your accident. However, if you live in a regular negligence state then you may use PIP or another coverage called Med Pay to cover your medical expenses.
Why PIP Coverage Matters
Understanding what PIP Legal is all about begins with a broad look at the benefits provided by PIP coverage. Every auto policy provides some level of PIP coverage because: it is mandated by all 50 states; it brings immediate financial benefits to the policyholder in times of need following an accident regardless of who is at fault; and it generally provides additional coverage for other family members. PIP coverage not only applies when the policyholder is involved in a car accident but also when using other forms of transportation or walking. PIP coverage is basically your travel insurance that applies to all forms of travel. The importance of this insurance can often be lost on policyholders who never use this insurance and are blissfully unaware of its invaluable benefits.
The facts are that every year, thousands of people just like you get into motor vehicle accidents. For those that do, PIP insurance coverage fills the gap of financial security that offers a variety of benefits to policyholders following an accident or injury. In Florida, these benefits include, but are not limited to, medical and prosthetic expenses, funeral expenses, wages lost due to the injury, and compensation paid to others (such as caregivers) for household services on behalf of an injured party. This is critical to policyholders and their families following an accident because these losses can be life-altering.
PIP coverage will pay for medical expenses for one year up to $10,000 without medical necessity. If further treatment is needed and the injuries have been proven to be more severe through documented proof of medical necessity, then PIP coverage will only pay for 80% of necessary and reasonable medical expenses. PIP will also pay 60% of lost wages and replacement services up to $10,000.
PIP also covers all reasonable and necessary expenses of an injured party as a result of a motor vehicle accident up to $5,000 if there is a serious injury. These expenses are known as "loss of services." This can be especially helpful during recovery for those who are married, care for children, disabled or elderly family members, or maintain a home or business. In the more tragic event of a fatality as a result of a motor vehicle accident, PIP will pay reasonable and necessary funeral expenses.
One of the most frustrating aspects of a car accident and PIP coverage can be the time it takes for bills from the accident to arrive. The speedy arrival of medical bills is often an unwelcomed surprise to the unprepared policyholder. In Florida, insurance companies are required to pay PIP claims simply because they were submitted and not questioned or disputed. Insurance coverage varies from state to state and the other 49 states have different rules and regulations. PIP Legal helps you navigate the maze of insurance requirements and assists in tough negotiations with the insurance adjusters.
PIP Claims: What You Need to Know
PIP stands for Personal Injury Protection. It is a form of insurance that covers medical bills, lost wages, and other damages sustained as a result of a car accident. Each policy can vary. It is not uncommon in the most basic of policies to have a twenty (20) percent co-payment responsibility that falls on the insured and other specific exclusions.
PIP applies to car accidents only. Bicycle, pedestrian, and premises accidents are not covered claims for PIP purposes. In order to file a PIP claim, one must obtain a prescription from an authorized medical provider for treatment within fourteen (14) days after the accident. That treatment must be "medically necessary," and follow all medical protocols. If the doctor is not covered under the N.J. No-Fault law, the claim will be denied.
The insurer typically has a set period of time to make a decision. That time period can range up to 30 days. If the claim is denied, the insurer must explain the reason for the denial. PIP claims are often limited to $250,000.00, and sometimes as low as $15,000.00. An issuance of a PIP denial letter can begin the PIP arbitration process.
Common Legal Disputes over PIP Claims
PIP litigation can be a long and challenging process. The most common legal issues that arise include a denied claim, insufficient coverage, or fraudulent activity. Denial of Claim: Insurance companies are tasked with determining the cause of a claim. If the injury did not occur in context of your auto accident case, or was exacerbated by something other than your accident, your insurance provider may deny your claim. Common insurance policy exclusions include, but are not limited to: · For intentional acts that result in bodily injury. · Driving while impaired. · Injuries that occurred in another country. · Using your vehicle to commit a crime. Your claim may also be denied if the coverage has expired or your auto accident was a hit and run. There are a number of other reasons that a PIP claim may not be approved. There is often a dispute when a claim is made remotely and the insurance company needs to determine if the accident occurred where it was reported, and whether the injuries were incurred from the accident and not the result of another issue such as a slip and fall. Your insurance may also deny your claim if there is no proof you were hurt, or a dispute over the extent of the injuries. Insufficient Coverage In order for your spouse to be included in your PIP coverage, you must file for spousal PIP. That may not be extended to other family members, however. Your PIP coverage is not determined by the number of autos insured in your household. Health insurance often times will not cover injuries you sustained in an auto accident, including in the context of spousal PIP. If you have exhausted your PIP, you will need to turn to your own health insurance or sue to recover medical expenses and lost wages as a result of your injuries. Fraudulent Activity Some individuals obtain PIP coverage and using it fraudulently. The most common cases of insurance fraud include: · Staging of an auto accident where the results are severe enough to warrant a personal injury claim and obtain money for recovery purposes. · In an effort to maximize PIP coverage, some individuals seek medical treatment that is unnecessary. · Claiming multiple injuries from automobile accidents and trying to commit double dipping while trying to recover from PIP and health insurance for the same conditions. · Suspicious signs of collusion between health care professionals and claimants, such as multiple claims from individual patients, or findings inconsistent with injuries claimed.
PIP Legal Obligations per State
The requirements for PIP coverage vary by state. For example, not every state requires drivers to purchase PIP. As of 2019, only 12 states and the District of Columbia have PIP laws in place on the books, and those laws range significantly in terms of what they cover. Not all states consider PIP insurance a mandatory purchase. Each state can determine whether its drivers will be required to purchase PIP and whether PIP will be purchased through an outside insurance company or self-insured.
New York requires most drivers to carry PIP insurance policies. A person who is injured in a car accident can file a claim with their insurance company, no matter who was liable in that situation. An injured driver in New York has to submit paperwork to their insurance company up to 30 days after the accident.
New Jersey and Michigan also regulate the amounts of compensation that can be paid out for PIP claims . New Jersey law outlines additional types of auto accidents, including serious bodily injury, and it makes a distinction between lawsuits that can be brought in an auto accident and those that cannot. Michigan law determines how the costs of accident-related compensation will be shared between the insurers and their clients.
Other states that require drivers to purchase some forms of PIP include Florida, Utah, Massachusetts, Kansas, Kentucky and North Dakota. For example, in Utah, PIP creates a streamlined process for filing claims, and an injured party recovers compensation regardless of who was responsible for an accident. Massachusetts PIP laws allow insureds to seek compensation for medical expenses, lost wages, replacement services costs and other damages.
The laws in these states and those where PIP coverage is optional differ in terms of things like minimum benefit amounts and coverage for high medical bills. These states often lack the tightly regulated processes for filing claims and the strict time limits that are common in states where PIP is mandatory.
Understanding How to Choose the Right PIP Attorney
You should never engage in PIP litigation without a qualified, competent, and honest lawyer representing you. How do you know if you have such a lawyer? You can ask them your own questions as part of your interview of the lawyer. Start with these:
- Has the attorney ever worked with PIP directly? Make sure the attorney who is going to be representing you practices PIP law every day. For example, when a physical therapist or chiropractor is owed money under PIP, they need to bring a lawsuit to get the money that is owed. A "litigator" who only brings lawsuits on behalf of other persons in a personal injury claim may not understand the nuances involved in a PIP lawsuit. Make sure you ask the attorney you are hiring the question above. Make sure the attorney has access to a litigator experienced in defending PIP lawsuits, if it does not litigate the claims itself on a regular basis.
- Does the attorney have any history of disciplinary actions against him or her? You can look up any disciplinary action on the Florida Bar’s website. All lawyers are subject to the Florida Bar’s oversight in everything they do. You should not sign up with a lawyer who is subject to disciplinary action. If he or she has a disciplinary history, you should select another lawyer to represent you.
- Is the attorney familiar with all aspects of your PIP claim, including the proper utilization manual to be used? All medical providers should utilize the appropriate rules and regulations as set forth in the Florida Administrative Code and the Medical and Surgical Fee Schedule adopted and incorporated by the Code. A good PIP lawyer will know right away what the appropriate fee schedule is for any type of provider who is owed money under the law when a claim is filed. It is important to get a good understanding of how much the claim is worth to you financially so that you do not sign off on the release in your case that waives all of your rights before accepting too little money from an insurance company.
- Unrealistic expectations: Be wary of a PIP lawyer who gives you unrealistic expectations on how long your case should take, how much your case is worth, etc. A good PIP lawyer will give you reasonable numbers based on experience and recent trends.
Latest PIP Legal Trends
There have been a number of recent PIP and property insurance cases that have held that a trial court’s order on a motion to compel or protective order are not appealable orders and there is a right of interlocutory appeal of a ruling on an order compelling discovery. In some unreported decisions the appellate courts have recognized the trial court’s discretion under the civil rules to limit discovery and such an exercise of discretion is not subject to review on direct appeal. Other opinions can be cited that apply the abuse of discretion standard in a discovery context.
In the case of the FHSMV vs. Allstate Case No. 4D06-3623 (Fla. 4th DCA 11/21/07, revising opinion issued October 31, 2007), the appellate court expressly rejected the order denying a motion to stay trial court orders pending appellate review of an order denying the insurer’s motion to compel. The court also rejected the argument that there is insufficient case law as to what type of discovery is permitted under Florida Statutes Section 111.321 and adopted the filing party’s suggestion that the court should adopt the federal rules of procedure and evidence in PIP actions.
In the unreported decision of State Farm vs. Mullinix, Case No. 4D07-2780 (Fla. 4th DCA 10/15/08) reversing the trial court , the appellate court considered the issue as to whether the circuit court had jurisdiction over an insurer’s claim for declaratory judgment regarding the statute of frauds and anti-fraud provisions of Section 627.736(8)(a) and (b) of the Florida PIP Statute. The Fourth District Court of Appeals held that the circuit court had jurisdiction over the declaratory judgment claim as the insurer had sufficiently pleaded that claims for PIP benefits were pending against it, that such claims were invalid because of the statute of frauds and/or violation of anti-fraud statute, and that the plaintiff had a duty to indemnify Plaintiff State Farm for any PIP payments arising out of Defendant Mullinix’s, residents of Monroe County, PIP action. Chief Judge Stevenson’s dissent noted the First District Court of Appeal’s decision in State Farm Mut. Automobile Ins. Co. v. Julian, 933 So.2d 654 at 655 (Fla. 1st DCA 2006), standing for the proposition that the circuit court only undertakes the statutory construction and interpretation of the PIP statute when the underlying action is venue appropriate for a circuit court. It is unclear how this issue will be resolved as there seems to be a split between the 1st and 4th District Courts of Appeal considering non-decision, non-binding opinions.