Personal Injury Protection (“PIP”)

Primacy of PIP coverage

Personal Injury Protection benefits:

• In New Jersey, PIP follows the person not the vehicle.

• PIP primacy starts with the policy for the auto you were driving at the time of the accident, or in the case of a passenger, the auto you own.

• If no coverage, then look to policies covering vehicles owned by resident relatives.

How do you get your PIP coverage to pay for your injuries?

If you are involved in an automobile accident, the benefit of seeking treatment under your Personal Injury Protection (“PIP”) policy is to receive prompt medical attention without the worry of having to pay out of pocket regardless of fault. Here, fault related to the accident may not be your primary concern. For non-emergency situations, your care may be subject to pre-certification requirements as set forth by the Automobile Insurance Cost Reduction Act of 1998 (“AICRA”). Understanding your injuries and the potential pre-certifications that may be required before you obtain medical care will help you maximize your PIP benefits.

Pursuant to AICRA, treatment of certain injuries, specifically to ones neck and back, may be subject to designated road maps as set forth by the New Jersey Administrative Code (the “Code”). Consider the Code a GPS when determining the course of your treatment. Just like a GPS, your roadmap here shows recommended routes or paths of treatment depending on your injury. The first road map deals with strains of your neck, specifically your cervical spine. A second road map outlines your treatment for more severe injuries to your neck, specifically herniations and radiculopathy to your cervical spine. A third road map deals with strains of your thoracic spine, which runs from your neck to your abdomen. The fourth road map deals with the aforementioned herniations and radiculopathy, but to your thoracic rather than cervical spine. The last two road maps deal with strains, and the more serious herniations and radiculopathy, of your lower back or lumbar spine.

What does your roadmap have to do with getting pre-certification? Throughout each roadmap of treatment there are points. At these points, your treating doctor must advise your carrier that they are present. When you come to one of these points, you must make sure that your doctor provides a plan of action going forward, specifically as to your future treatment. Your carrier can them approve, or deny the proposed plan of action. In certain situations, your carrier may require you to submit for a medical exam, of their choosing, to help determine if the requested plan from your doctor is viable.

Making sure you get pre-certification is extremely important. If you do not receive this approval, your carrier may deduct from what they would normally pay in reimbursement. That could be money out of your pocket! Remind your doctor is to meet all his or her pre-certification requirements for your care.

PIP Arbitration

You are hurt while in an automobile and you want treatment fast. You don’t have the time file a lawsuit against the person who struck you and you just want to get better. Immediately you seek medical treatment under PIP. Your doctors dutifully submit treatment plans and medical bills to your carrier following their PIP guidelines to a T. Suddenly, your carrier says they won’t approve a treatment plan or pay your bills? Outraged, you want to sue your carrier! But can you? Probably not, but there is hope!

You will likely bring your claim against your carrier in arbitration. Under New Jersey law, “If an insured or treatment provider seeks to recover payment of bills or seeks to compel the insurer to authorize treatment of the insured, the PIP statute permits either side to choose binding arbitration or the filing of a lawsuit with the New Jersey Superior Court.” N.J.S.A.39:6A-5.1. This statute requires the Commissioner of Banking and Insurance to designate an entity for conducting arbitrations. The current entity is Forthright, which utilizes in-person and paper arbitrations.

The arbitration process is streamlined. It requires you to make a demand, and the respondent to provide a statement in response. We note that either you, your doctor or the carrier itself can demand arbitration. The matter is heard by an arbiter, called a Dispute Resolution Professional, who can render a decision, and has the ability to assign fees and costs. If you don’t like the result, you can always appeal to a three DRP Panel.

There are many great benefits to using the arbitration process. Documents are submitted electronically, the rules of the forum are right on Forthright’s website, you get quick decisions and it’s cheaper then filing suit! On the downside, you don’t necessarily get the benefits of the rules of procedure and evidence you would in court. Additionally, you can’t utilize normal discovery procedures like depositions.

But carriers are sneaky! Make sure you check your policy to see if your carrier first requires you to appeal a denial through an internal process before demanding arbitration. Not doing so can act as a total defense to a subsequent arbitration or lawsuit.

Want to demand arbitration for an accident that occurred in Morris, Essex, Hudson, Bergen, Middlesex or Passaic County? Let the experienced PIP team at Verp & Leddy guide you through the process!

What PIP Coverage am I Entitled to?

There are several different types of PIP coverages you may choose from in selecting your automobile insurance policy. The default option you may choose is for $250,000.00 in PIP coverage. At one time you were bound by this standard limit. However, now New Jersey law allows you to save money on your premiums by getting PIP coverage of lesser amounts. However, you may not realize the consequences of the coverage you selected until after you are already hurt. It’s important to know what rights you have.

If you did elect the standard PIP limits, you have the most available coverage. You have $250,000.00 available in coverage for reasonable, necessary, and appropriate treatment and provision of services to persons sustaining bodily injury per person per accident. You also receive up to $100.00 per week in lost income up to $5,200.00. Additionally, if your injuries cause you to have to hire help for your personal or family affairs, your standard PIP election has you covered. You may be reimbursed up to $12.00 per day up to $4,380.00. Third, your standard policy provides financial relief in the event you die. If you are the primary income producer your estate can recover death benefits up to the maximum amount you could have earned in income continuation benefits of $5,200.00. Additionally, if you provided essential services such as those described above, you can receive up to that maximum of $4,380.00. Lastly you get funeral and burial benefits up to $1,000.00

If you elect basic PIP coverage, you only have benefits of $15,000.00. You cannot recover income continuation, essential services, or death benefits. However, you can have up to $250,000.00 for certain serious injuries. These are limited catastrophic injuries including permanent brain damage, spinal cord injuries, and disfigurements. The $250,000.00 is also available if you immediately go to the hospital after your accident with a serious injury.

Lastly, in certain circumstances, you can elect to receive limited PIP coverage under a “special policy.” This is eligible to only lower income individuals. With this policy, you only receive $10,000.00 in death benefits. However, if you do have the benefit of $250,000.00 in coverage for your emergency care after an accident in which you received serious injuries.