Insurers CANNOT unilaterally deny your charges citing a $2,500.00 cut-off. PIP Insurers are likewise not permitted to utilize an EMC “doctor” to cut off PIP benefits citing the belief your patient did not suffer from an emergency medical condition.
Insurers are left with 2 Options under the statute:
- Pay-If they receive the EMC note/document
- Do not pay and Request an EMC determination from the provider
- Utilize a cut-off indicating the doctor notes are improper or do not rise to the level of an EMC.
- Pay a peer review or IME doctor to cut off benefits alleging the patient did not suffer from an emergency medical condition.
What are insurers doing as of today?
Some insurers are fighting back by stating your treatment isn’t reasonable, related or necessary. WE believe this to be an excuse to deny based on the EMC determination. Insurers cannot deny EMC determinations once in possession of them.
Remember, EMCs can be sent to the insurance company at any time. However, if you use an attorney’s services, you must consult with him/her prior to filing suit. An EMC determination furnished to the insurer may cause a premature lawsuit in some cases.
Make sure you get an EMC determination at some point. Send it to the insurer with your bills. Include the EMC in your medical notes. Most insurers do not take the time to read your notes. If you send your notes with your bills and later file suit on the same, the insurer cannot argue you didn’t furnish them the necessary documents. To the contrary, you provided the insurer with what they needed; however, they didn’t take the time to review your medical records. This then is an insurer problem, for which you will receive payment plus interest.
We will file appropriate motions to ensure the insurance company CANNOT cut-off benefits because of a straw-man. INSURERS CANNOT tell you your EMC note was not sufficient. NO magic words are necessary to determine whether your patient suffered from an EMC. Moreover, insurers cannot use their own physicians to cut benefits for EMC purposes. Do not let the insurer play mind games with you. Contact me to discuss our PIP litigation services and how we can maximize your bottom line!
DO NOT HESITATE TO GIVE US A CALL!
CASE LAW REVIEW:
The case was decided on December 8, 2014. The medical provider’s notes did not explicitly state that the patient suffered from an emergency medical condition. However, the honorable 9th judicial circuit ruled in the Provider’s favor. The 9th Judicial Circuit opined that a broken bone in the patient’s wrist rose to the level of an emergency medical condition. As of now, this case has not been appealed. Moreover, this author has yet to find another case in which the Court agreed that a serious injury afforded for the full $10,000.00 of PIP Benefits under the policy in the absence of an emergency medical condition determination.