Northwoods Sports Medicine and Physical Rehabilitation, Inc., and Wellness Associates of Florida, Inc. v. State Farm Mutual Automobile Insurance Company and USAA Casualty Insurance Company was decided on March 5, 2014. “Northwoods” shocked the PIP world, as the 4th District Court of Appeals determined that benefits are exhausted whether the exhaustion occurs before or after a lawsuit is filed. However, the LaBovick Law Group Pip Team has several solutions to ensure recovery despite the “Northwoods” decision. Please continue reading to discover how you can continue to defeat the insurance company despite benefits becoming exhausted.
1) REQUEST DOCUMENTATION FROM THE INSURER
The PIP insurer has no obligation to send you a PIP log until 30 days after a lawsuit is filed but must alert you of benefits exhausting within 15 days of exhaustion. However, how can one decide whether benefits exhausted properly without a PIP Log or a document explaining how and why benefits were exhausted.
If the insurer refuses to send you a PIP LOG, call us. We have recently formulated an approach to securing the insurer’s compliance with our demands. The next question is: how I can utilize a PIP LOG to my advantage?
2) GRATUITOUS PAYMENTS AND THE PIP LOG
A gratuitous payment is no payment at all. A gratuitous payment is simply an untimely bill sent to the insurance company by the Medical Provider. Generally, a medical provider has 35 days to bill the insurer for medical treatment rendered. A bill sent on the 36th day would be considered untimely. Any payment made by the PIP insurer to the untimely bill sent by the provider is considered gratuitous and would NOT affect the limits of the $10,000.00 PIP Policy.
Example: Provider “A” treats Chris Bosh on September 1, 2015. Provider A submits its bills to State Farm on October 28, 2015. Provider A’s bills are untimely unless they sent a Notice of Initiation of Treatment to State Farm. If State Farm pays Provider A $100.00, the payment is considered gratuitous in nature, and you have the right to recover the $100.00 remaining under the policy.
GRATUITOUS PAYMENT FORMULA: $10,000 (PIP POLICY) – $9,900 (Amount paid by PIP insurer) = $100.00 left under the policy after the gratuitous payment.
*** A GRATUITOUS PAYMENT IS NO PAYMENT AT ALL FOR PIP PURPOSES*** Thus, whatever amount the insurer pays to another provider for untimely bills, can be collected by us in a PIP suit.
3) WHAT TO LOOK FOR ON A PIP LOG
Let’s start with this premise: a PIP Log is crucial to determine whether benefits are truly exhausted and to determine how much was actually paid by the insurer. Pip insurance adjusters are human. They make mistakes. We cannot always take their word as to whether benefits remain, and what amounts they truly paid your clinic. Thus, we request a PIP LOG. PIP Logs are not created equally. Generally, they contain the date(s) the patient was treated, the amount billed, the amount paid, and the date the bill was paid.
HOW IS THIS HELPFUL?
A. We can determine when a gratuitous payment was made to truly discern how much PIP ($10,000 policy) is available.
B. We can determine how much the insurer paid you.
C.We can find out how the deductible was applied to determine whether your bills were paid correctly.
D. We can determine when each bill was paid, why it was paid, how it was paid, and determine what is the next step in the process.
4) Explanation of Benefits (EOBs)
Explanations of Benefits are generally provided by the PIP insurer with their response to your claim or HICFA. The EOB indicates how much service was reimbursed by the insurer, and also includes an explanation code signifying the reason for payment or lack thereof. For example, a CPT Code may be reimbursed per Medicare Fee Schedule. The corresponding Explanation will indicate why and how it was paid (Medicare Fee Schedule).
EOBs should tell us why the insurer refuses to make the correct payment. However, if the EOBs are unclear and the insurer eventually raises additional defenses, we can argue the insurer waived their right to fight because of their vague EOB. EOBs help us determine litigation strategy. The insurer has a duty to provide you with these documents. If they do not and refuse to, please contact us. We’ll happily file suit to ensure your recovery.
EOBs generally contain The date of service, the amount billed, and the amount reimbursed, in addition to a reason code. (EX: 721). The reason code will provide an explanation as to why the insurer paid the amount they paid as opposed to the amount billed. Florida PIP statute sections may be quoted.
A.If you receive an explanation code specifying Statute Section 627.736(6)(b) commonly called a 6B request, please call us at your earliest convenience.
B. A 6B request is simply asking for further documentation in order to evaluate payment.
C. However, remember this mantra, NOT all requests are created equally
1. We have years of experience dealing with insurer shenanigans.
2. We will make the appropriate objections and ensure your private documents remain private.
LaBovick Law Group prides itself on staying ahead of the curve when it comes to innovative approaches to PIP claims. Our PIP team litigates against the PIP insurers on a daily basis. We’ll ensure you get all of the PIP monies due and owing. We have advanced systems in place to ensure all ancillary issues are litigated in addition to the incorrect payments made by the insurer. PIP LOGS and EOB’s are crucial documents. If the insurer makes a business practice of omitting the service of these documents, please call us. Do not take the insurer’s word as to the exhaustion of benefits. Send us all relevant documentation for evaluation!