Recently in NJ there have been a couple of cases regarding medical expenses that have exceeded the limited Personal Injury Protection (PIP) coverage benefits and what fee schedule should be used for the medical bills in excess of the policy limits.
The first case is Viruet v. Maoine in Cumberland County in 2016. The question in this case was whether reimbursement for all plaintiff’s medical expenses, incurred because of their auto accident, be limited to the NJ MV PIP fee schedule and not just those expenses covered by the plaintiff’s $15,000 PIP policy. The plaintiff incurred medical expenses in excess of $56,000. The contention was not that plaintiff could seek economic compensation for the expenses incurred that were above the 15k policy, but rather that the expenses beyond the 15k should be limited to the NJ PIP fee schedule. This would have limited the dollar amount received by Plaintiff given the fact that this fee schedule generally pays at a much lower rate than UCR fee schedules. The court ruled in favor of the plaintiff indicating they were not prohibited from recovering the full amount of medical expenses incurred in excess of the 15k PIP policy.
The court came to this conclusion based on three points. First, the PIP carrier is not paying the medical expenses above the policy coverage limit, so the PIP fee schedule does not apply. Second, since the services provided are not covered by PIP, the medical provider is not limited to the PIP fee schedule when billing the patient and is free to bill for the full cost of the treatment, meaning that the plaintiff is then responsible for that full amount billed. Finally, due to the nature of the no-fault system, the plaintiff must go through the lengthy process of providing evidence, proving liability as well as reasonable and necessity of medical bills, their expenses won’t be instantly recovered. Even if they are successful at trial, collection of damages may be further delayed or limited based on the defendants’ insurance or financial situation. In this case, it was left to the jury to decide the fair and reasonable value of the $45,000 balance of the incurred medical expenses. This is a prime example of being ahead of the curve. Employing a certified medical biller/coder, in this case, would greatly support the actual value of the medical expenses and support the settlement amount.
More recently, in April 2017, we see Haines v. Taft argued in the Superior Court of New Jersey. The question, in this case, is whether the inadmissibility of evidence of losses, collectible under PIP coverage statute, precludes the recovery of medical expenses above those collectible or paid under a PIP policy, including medical expenses exceeding an elected PIP option. Specifically, plaintiffs, in this case, we’re seeking recovery of medical expenses in excess of their elected $15,000 PIP policy. Defendants argued that they could not be held liable for any expenses between $15,000 and $250,000, given that the “usual PIP limit in a standard policy” is $250,000. While it is true that the PIP benefit defaults to $250,000 if no option is chosen by an insured, there are indeed separate options, including $15k, $50k, $75k, etc.
Overall, the court ruled that those who choose PIP benefits for less than $250k take the risk of not having medical expenses immediately paid regardless of fault and need to pursue litigation to recover losses, in exchange for paying less for premiums. They ruled that in these cases, medical expenses between the PIP limit selected and the standard of $250,000 are admissible as uncompensated economic loss that can be recovered.
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