Posted January 21, 2017 - Phillip C. Gilbert, Attorney at Law
If you watch mainstream television, then you are aware of the fact that many of the nation’s largest insurance companies have chosen to woo customers with funny commercials, i.e. Flo from Progressive, the “Mayhem” Allstate spokesman, Geico’s infamous gecko, etc., etc. The thing is, these ads have zero to do with the quality of the product that you receive, and we all want true “protection” in the unfortunate event that we’re involved in a car accident.
Something that absolutely is not funny is the disturbing fact that, when it comes to an insured’s own PIP claim, the large insurance companies seem to be requesting that the insured attend “Independent Medical Examinations” more often, and earlier on. As is discussed elsewhere on this website in more detail, “PIP” is the acronym used in the industry when discussing “Personal Injury Protection” coverage. PIP coverage is a first party coverage; meaning that our own insurance policies include this coverage (as opposed to being a coverage available through the policy covering another vehicle in those cases where a car accident is caused by someone else). This coverage is mandatory in Oregon (for automobiles, not motorcycles). It includes reimbursement of an insured’s medical care costs, for up to one year after the date of a car accident, and up to the amount of the policy coverage limit (Oregon law mandates that all policies issued in Oregon provide a minimum of $15,000.00). The coverage is available for care reasonably related to injuries suffered in a car accident.
In my experience (this is my 31st year in the industry, and I first worked for a very large insurance company and then law firms hired by insurance companies), the larger insurers are increasingly becoming more and more aggressive in challenging whether medical care that their own, premium-paying insured receives after a car accident, is needed (if the care in question is determined/claimed to not be reasonably necessary, the insurer will refuse to reimburse the insured’s medical care providers’ bills, leaving the insured personally on the hook to pay those bills). What happens in this scenario is that your own insurance company – the one that you have been paying hundreds (or more) of dollars a year to – requests that you attend an Independent Medical Examination; ostensibly for the purpose of having an allegedly “independent” physician examine you, and review your medical records, and thereby determine whether you need/needed medical care past a certain date. The dirty truth is that these examinations are almost never “independent.” The insurance companies tend to use the same batch of physicians over and over again and, guess what: it turns out that these physicians’ reports almost always end with the conclusion that the insured does not need any more medical care whereafter the insurance company refuses to pay your medical care providers’ bills. Some would describe this process as being a “racket.” Indeed, in many, many cases, the content of the “independent” physician’s report reads like dozens of other reports that they have generated. The punch line is often to the effect of: the person sustained a “soft tissue” injury and the medical research confirms that all such injuries completely resolve within 6 weeks; 3 months at the outside.
I will save a discussion of “soft tissue” injuries for another article but do want to add another word to the wise; referring to you, when you are injured in a car accident and require medical treatment for your injuries. Specifically, I would note that in my experience some of the insurance companies are relying upon “records reviews” in lieu of independent medical examinations. In a “records review,” a doctor is supplied with copies of the insured’s medical records and asked to comment on the reasonableness of their medical care. In essence, a records review is like an independent medical examination but without the examination. (USAA goes this route frequently). Predictably, the reviewing physicians seem to almost invariably conclude that the medical care in question is not needed, and the insurance company relies on that opinion to discontinue benefits. What I have noticed – in the trenches, if you will – is that the doctors that are used to perform these records review may have dubious qualifications. For example, last year we received such an opinion letter-coverage denial based upon the conclusions of an acupuncturist, from Colorado, whose own website revealed that they claimed to specialize in “facial rejuvenation” and “infertility.” This is but one example.
The upshot here is that even though your insurance company’s television commercials seek to assure you that they are on your side and will protect you well if and when you open a claim, in the vast majority of cases that is not in fact the case; and you’ll end up needing to lawyer-up.