By: Karen Piso Nadeau, Esquire

Whether you are the driver of a vehicle, a passenger in a car, a pedestrian crossing the street, a bicyclist, or riding a scooter when struck by a vehicle, there is a lot of stress and uncertainty surrounding how your medical bills get covered and paid. This blog will explain how the law works in Massachusetts to cover your medical bills and provide some insight on how to tackle your medical bills if you are injured in a car accident in Massachusetts. Based on my experience representing victims injured in auto accidents in MA for over 3 decades, the good news is that there usually is plenty of insurance coverage to get your medical bills paid. The difficulty typically encountered is how to coordinate benefits and make sure your medical providers have the necessary insurance coverage and information to properly bill the insurance companies.

Massachusetts Has No Fault Auto Insurance

Massachusetts has no fault auto insurance providing medical expense coverage with a typical $8,000.00 policy limit per person injured. This no fault coverage is called Personal Injury Protection benefits known as PIP benefits. If you look at your auto insurance coverage selection page, you will see the section under Compulsory Insurance Part 2. This means regardless of who is at fault for the accident, the PIP benefits will cover an injured party up to $8,000.00. This means if you are driving your own car and run a red light or rear end someone and you are injured, you still have the $8,000 in PIP coverage.

Who is Covered Under the PIP Benefits?

Clients calling us usually do not know that PIP benefits are available to them or what kind of insurance provides these benefits. As a new lawyer finding my way many years ago, my mentor taught me to think about what vehicle touches the injured party to determine what PIP benefits will cover an injured client. When you apply this to an accident scenario, the PIP coverage that applies becomes clear.

1. Driver and their Passengers

The driver and their passengers injured in a car accident will have PIP coverage provided by the auto policy of the car that they are riding in. So, if you are a passenger in a vehicle, the PIP is provided by the insurance of the car that you are riding in.

2. Pedestrian

A pedestrian struck by an automobile has PIP coverage provided by the vehicle that struck them.

3. Bicyclist

A bicyclist struck by a car has PIP coverage provided by the car that collided with them.

4. Scooter, Skateboard, Wheelchair

Similarly, if you are riding a scooter, a skateboard, or in a wheelchair, the vehicle that contacts you will provide the PIP benefits for you.

How Do You Begin the Process of Obtaining PIP Benefits?

To obtain PIP Benefits, you need to open a PIP claim with the auto insurance company that will cover you. Identifying the auto insurance is not always easy. Of course, if you are the driver of a car or a passenger, then it should be easy to identify the auto insurance and contact them. When you are a pedestrian or bicyclist, identifying the insurance for the vehicle that collided with you is not so easy. In the best of circumstances, police are on scene and secure the necessary information for the driver and their car insurance and provide you with an Exchange Form with the information. The Police Report may contain the auto insurance information for the car that struck you. Perhaps the driver at the scene exchanges information with you providing the auto insurance. However, sometimes this is not the case, and the police actually cover up and delete all the driver information such as address, date of birth and insurance information claiming the driver’s right to privacy and or confidentiality- which I find outrageous for an injured victim who reasonably relies upon the law enforcement to secure the needed information for them. As the lawyer for injured parties, we sometimes need to file appeals with the Town or State Police where the police have refused to voluntarily give us the needed information so our injured client may make the necessary claim. It is sometimes a frustrating process to simply obtain the driver’s auto insurance.

Filing a PIP Application & Consent to Release Medical Records

Once you open a claim with the PIP insurer, the insurance representative will send you a PIP application to be completed. This is usually required to obtain any PIP benefits. At my law firm, we complete these forms for our clients with the information they provide and have them sign off. We then submit the PIP application to the insurance company on their behalf. As part of this PIP application, the insurance company will require you to sign authorizations allowing them to obtain the medical records related to your accident.

Other Requirements that May Be Requested of You for Your PIP Claim

The PIP insurance adjuster may request your recorded statement whereby they ask you permission to be tape recorded and they ask you questions about the accident, your injuries, your medical treatment and any time missed from work. If there are questions about your injuries and treatment and to what extent they are reasonable and necessary and related to the auto accident, the PIP insurance company may request that you be seen by a doctor that they choose for an examination on a specific date. This is called an “Independent Medical Exam”, also known as an IME in the legal industry. When a client retains my firm to represent them for their car accident, all communication with the insurance company legally must be with us, your lawyer. The insurance company is forbidden from contacting you once you are represented by counsel. We handle all the requests for recorded statements and independent medical exams for our client to make sure their case is in the best possible position for success.

It is important to know that recorded statements may be used against you for the insurance company to deny or limit your PIP claim. Sometimes an injured party has no idea that the way they answered a question may be twisted and used against them at a later date. As to Independent Medical Exams, they are anything but independent. The insurance company sends you to a doctor of their choosing, and this doctor gets paid by the insurance company to examine you and write a report documenting the extent of your injuries and necessity of ongoing causally related treatment. Some of these doctors have performed hundreds of these Independent Medical Exams for an insurance company. The reports often come back in favor of the insurance company, cutting off payment for ongoing treatment, by saying the medical treatment is no longer necessary.  Again, when we represent a client injured in a car accident, we make sure to level the playing field and know how to handle these IME’s, including getting a rebuttal letter from one of your treating doctors  to say why they disagree with the IME doctor.

Coordination of Benefits  

In Massachusetts, the law requires a coordination of benefits between your health insurance and the PIP insurance. There is law that states how your medical bills are paid and coordinated when you are in an auto accident. If you have private health insurance such as Harvard Pilgrim or Blue Cross for example, the law states that PIP must cover your first $2,000.00 in medical bills related to the car accident. Once PIP pays the $2,000.00, the insurance company will issue a PIP exhaust letter stating that they have fulfilled their obligation to pay $2,000.00 in PIP benefits. This letter is very important because it then legally triggers your health insurance to pay your medical bills related to the car accident in the usual manner they normally would.

As part of our representation of our clients, we secure this PIP exhaust letter to make sure the outstanding medical bills over the $2,000.00 are paid by the client’s private health insurance. Any medical expenses not covered by health insurance such as copays and deductibles will be covered by PIP up to the $8,000.00 max typically.

There are some exceptions to PIP paying only the first $2,000.00 in medical bills. For example, if a client has Mass Health, then typically PIP must pay the full $8,000.00 before Mass Health pays any medical bills related to the accident. There is also some health insurance plans called ERISA plans that require PIP to pay the full $8,000.00 before they are required to pay any medical bills.

Other Losses that May Be Covered By PIP

In addition to medical expenses, PIP will also cover your lost wages at 75%. What this means is that if you lose $1,000.00 in wages due to your injuries and disability from work, PIP will reimburse you $750.00. Two things are needed to obtain lost wages from PIP: 1) a disability note from your doctor stating that you are disabled from work due to your injuries from the accident with the dates that you are unable to work; and 2) verification of your wages from your employer. Again, when we represent a client who suffers lost wages in a car accident, we facilitate them getting paid by PIP for the loss.

PIP may also cover transportation costs to and from medical appointments such as a taxi ride or Uber.

It is important to note that there is a total of $8,000.00 per person typically in PIP benefits to cover any of these expenses.

A Final Consideration on PIP Benefits

In a perfect world, the payment of PIP benefits and coordination of benefits goes smoothly, and all your medical bills related to the car accident get processed and paid timely. This is far from reality. It is not unusual for example for an injured party to get an ambulance bill for their ambulance ride from the accident scene to the hospital months after the accident saying they owe $2,400.00 or even more. More often than not, our client does not owe the bill, but the ambulance billing department does not have the PIP or health insurance information needed to get the bill paid.

Also, medical bills “get stuck” for months where they are in limbo “being processed”. Sometimes there are collection notices or balance overdue letters sent to the injured person’s home making them very anxious. No one wants to get an overdue medical bill in the mail for thousands of dollars.

At our firm we have day to day experience helping our clients through this process and help alleviate the worry and stress caused by a less than perfect system that often seems difficult to navigate. In the end, I can say that things usually work out with some persistence and follow up, and PIP and health insurance coordinate benefits so that the medical bills related to your car accident are paid.

At Nadeau Harkavy LLC, we have over 60 years combined experience representing injured people and their families when they have been involved in a motor vehicle accident, trip and fall or other type of accident. We have recovered millions of dollars in compensation for our clients over the years to help them get on with their lives after suffering the consequences of a serious accident.  We make sure everything is done to protect your interests while you and your family concentrate on getting better. We handle all types of car accident cases including wrongful death and brain injury. We represent drivers, passengers, pedestrians, bicyclists, as well as other types of car accident cases such as scooter, motorcycle, and skateboard cases. We also handle other types of injury cases such as trip and fall, slip and fall, dog bite, construction site, and catastrophic injury accidents. If you or a loved one has been harmed through no fault of your own, call us today for a free consultation about your legal rights at 617-674-7640.