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PIP Medical Providers and Basic Policy Exhaustion

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Tammy Kotsev

Written By: Tammy Kotsev, PIP Attorney at Callagy Law

New Jersey allows for a statutory exception to Basic Policy coverage limits of $15,000 per person, per accident for medical coverage in the following circumstances:

(1) for all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or (2) for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requires critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician.

N.J.S.A. 39:6A-3.1.  Treatment falling within this exception shall not to exceed $250,000.  N.J.S.A. 39:6A-3.1.  As a result, a Basic Policy is essentially converted to a $250,000, which can be vital in overcoming a denial based on Basic Policy exhaustion.

So what factors will determine that a carrier should increase the PIP coverage limits of a Basic Policy to $250,000?  In one instance, a DRP found that additional coverage for a Basic Policy was not triggered by the fact that the injured party sustained “injuries to her face, head, and scalp [including] facial lacerations and a scalp laceration that was 20 centimeters long.”  There, the DRP concluded that the injuries did not meet the “permanent or significant” threshold required by N.J.S.A. 39:6A-3.1.

In another matter, a DRP found that the claimant provider had “proven by the preponderance of the credible evidence that the patient received critical care at a designated trauma center,” thereby reforming the Basic Policy to a $250,000.  The DRP considered the following facts to be persuasive in reforming the Basic Policy:

  • The motor vehicle accident occurred one day prior to the first day of treatment by the claimant provider;
  • The claimant provider was designated a Level II Trauma Center; and
  • The patient had received critical care on the dates of service in question.

Notably, the Basic Policy was reformed to a $250,000 policy for only the two dates of service that were found to represent critical care.  By way of comparison, x-rays performed almost four weeks after the same accident were found to fall outside of this statutory exception for Basic Policy coverage limits.

Essentially, the issue of whether a Basic Policy may be reformed to a $250,000 policy turns on a claimant provider’s ability to establish, in addition to medical necessity, one of the following issues were caused by the motor vehicle accident:

  • Permanent or significant brain injury, spinal cord injury, or disfigurement; or
  • Other permanent or significant injuries (so long as treatment occurred both (1) at a trauma center or acute care hospital; and (2) immediately following the motor vehicle accident and until the patient is stable).

In deciding a PIP matter, a DRP will likely look for facts and circumstances showing that the treatment was part of the critical care for injuries sustained during the motor vehicle accident.  For instance, a claimant provider should be prepared to answers the following questions when seeking to trigger reformation of a Basic Policy to a $250,000 policy:  How close in time was the treatment to the accident?  Was the treatment medically necessary?  To what extent could the sustained injuries be deemed “permanent or significant”?  Where did the treatment occur?

Additionally, a DRP will also consider the attending physician’s recommendations as to whether the patient was stable or able to be safely transferred.  Moreover, the attending physician’s findings regarding the nature and extent of the injuries will be crucial in meeting the “permanent or significant” threshold.

Once a claimant provider has established that the treatment falls within the exception of N.J.S.A. 39:6A-3.1, the Basic Policy may be reformed to a $250,000 policy.  However, such reformation will likely be limited only to those treatments falling within the exception, as N.J.S.A. 39:6A-3.1 does not provide a blanket exception for any and all treatments rendered as part of the claim.  Denials based upon Basic Policy exhaustion should be carefully reviewed for any possible statutory exceptions, triggering reformation to a $250,000 medical coverage policy.

DisclaimerThis article is meant to be informative only and is not intended as, nor should it be construed as, legal advice. This article is meant as a general guide only and does not address all possible circumstances that could affect the rights and limitations of undocumented workers.  If you are injured on the job and sustain injuries you may wish to contact an experienced attorney for legal advice, regardless of your immigration status.

Original Article:

http://callagylaw.com/provider/

For more information please visit:

www.callagylaw.com

www.callagycounsel.com

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