In an ideal world your insurer would pay out on your Personal Injury Protection (PIP) claim without question.
But the reality is that many insurance companies focus on finding issues with your claim, allowing them to either delay or decline payment.
When these situations arise – and it happens all too often – you have the right to appeal your claim through a PIP arbitration process.
The good news is that most Personal Injury Protection policies provide a framework for this type of dispute resolution, because the reality is that if your insurer does not cover your medical expenses there’s a very good chance, they’re in breach of contract.
Why Is Arbitration Necessary?
In many cases the victim of the accident is informed they didn’t meet one of the following requirements, which then results in payment of medical and other expenses either being declined or unjustly delayed:
- The patient is not covered by, or ineligible for, Personal Injury Protection
- Treatment received was not pre-certified
- Treatment was deemed unnecessary
- Insurance company claimed patient didn’t cooperate with them
- Policy limits were exceeded
- Incorrect billing codes used
- Documentation provided was deemed to be inadequate
Now we need to look at what’s actually required for your PIP arbitration
State Laws
The first thing to check is what the requirements are for your state. You can take some of the guesswork out of this by consulting with a lawyer with PIP arbitration experience.
Appeal Internally Before Arbitration
Most claimants will seek legal advice before trying to appeal the matter directly with the insurance company, most of whom have an internal process for this. Whenever possible, always exhaust the internal appeals process before moving to arbitration simply because it paints you in a better light.
Proof of Pre-Certified Treatments
Most medical and healthcare professionals know that insurance companies will use this loophole to avoid paying a PIP claim. So, any documentation you have that can prove your treatment was pre-certified is an essential part of your appeal and the arbitration process itself.
Proof of No Coverage
Certain types of insurance companies will claim that you have no PIP cover and/or that you declined cover when you sent your policy documents back to them. In these situations simply ask for signed proof that you declined Personal Injury Protection as part of your motor insurance policy.
Medical Reports
This should include any and all treatments you received, including EMGs, MRIs, etc. Although insurance companies will often content these treatments, providing proof that they were necessary is required. You should also include itemized medical bills with your appeal.
Assignment of Benefits
This is proof that you requested that payment for your medical costs be made directly to a nominated facility or physician. Not every PIP arbitration case will require this, simply because not every claimant makes this arrangement with their healthcare provider.
Explanation of Benefits
This is basically a billing summary from your insurance provider which shows what was paid to your healthcare provider, and how much was paid to you, the patient.
Witnesses
Although this doesn’t always happen, it’s a good idea to notify your doctor, or other witnesses, that they might be required to answer questions in front of an arbitration panel.
Summary
Arbitration has become an unfortunate element of making a Personal Injury Protection claim for many people, but once you\’re prepared for the process you should find that it’s very straightforward.