PIP Benefits Do Not Hinge On Application Alone

Boston Municipal Court’s Appellate Division recently decided an important case clarifying a Massachusetts insurer’s use of the Personal Injury Protection Application in relation to extending Personal Injury Protection benefits. Boston personal injury and car accident attorney Thiadora A. Pina, of the Law Office of Neil Burns, notes this case lends direction to a long standing issue regarding payment of PIP benefits. “Massachusetts insurers have long held to the notion that you must return their individual form in order to be eligible for PIP benefits,” notes Attorney Pina. “Finally, we know the issue remains prejudice to the insurer, not what particular form is filed.”

The facts of the case recently decided concerned a 2005 motor vehicle accident. The injured party was a passenger in a motor vehicle insured by defendant Pilgrim Insurance Company. The policy was considered a “standard Massachusetts automobile policy” which included PIP, or personal injury protection insurance. This insurance, known as no-fault, provides up to $8,000 for medical bills and a percentage of lost wages.
In this case, six days after the accident, on February 8, 2005, Pilgrim was notified of both the accident and the claim by its insured, and of the injuries sustained in the accident. They immediately sent out a PIP letter and form. The same documents were sent to the insured’s attorney on March 14, 2005 after Pilgrim was notified that its insured had retained counsel. Pilgrim did not receive a completed PIP form from either the insured, or her attorney. In a letter dated August 15, 2005, the attorney notified Pilgrim that he no longer represented the insured.
The insured was treated by Advanced Spine Centers, Inc., and was billed almost $6,000.00 for its services. The medical provider sent reports and bills to Pilgrim on a regular basis. In response, Pilgrim sent form letters advising that it was unable to issue payment because it was “waiting for the insured to submit an application for benefits.” On July 12, 2006, Pilgrim sent Advanced Spine the same form letter, but inserted the following language, adding the following “Personal Injury protection benefits were denied. P lease contact the claimant for additional information.”
Advanced Spine sued Pilgrim for payment. Attorney Frank Gaimari, a well-known counsel for plaintiffs, represented the physicians. The issue was whether the insured’s failure to submit the specific PIP package sent by Pilgrim was a material breach of the cooperation clause of the standard automobile policy and a violation of Massachusetts General Laws, Chapter 90, §34M, which precluded her recovery (and, thus, Advanced Spine’s) of PIP benefits.
The Court concluded that the “standard” auto policy did not require a PIP form. Nor did Chapter 90, §34M. The Court found no prejudice to Pilgrim because it was in possession of all the documentation it needed – regular reports, treatment notes and bills – from its insured. Wherefore, Pilgrim was ordered to pay the medical bills.