Medical Bill Reimbursement After Motor Vehicle Accident

Even though we have no-fault insurance for the first $8,000 of medical bills after an auto accident in Massachusetts, the motor vehicle insurance companies are relentless in trying to cut back reimbursement to medical providers.  A case that came down from the Appellate Division of the Massachusetts District Court is a case in point.

When New England Sports Therapy filed a lawsuit against MetLife Auto and Home Insurance it was because MetLife failed to pay the full bill for their insured’s physical therapy at NEST.   This seems to be a common theme, as we reported a case by chiropractic against Amica Insurance earlier this year.

The case against MetLife, involved the Court determining whether the billings by NEST were reasonable verses the reasonableness of the payment by MetLife.  The Appellate Division found that there was insufficient information on the record to determine if the case was decided properly by the trial judge.

Massachusetts General Laws Requires Reasonableness In Medical Billing

 The law, Chapter 90, Sections 34A and 34M says that PIP insurance must cover all reasonable expenses for necessary medical services.  Typically, the insurance company will send you to their insurance doctor who will say you are all better and that it would be reasonable to stop treatment.  This gives the insurance company a method for cutting payments, and still seeming to fulfill the reasonableness requirement.

What if, for some reason, they didn’t get a chance to do this?  Or, they determine that the provider is overbilling, not just you, but many patients.  What can the insurance company do?  They can determine that the will cut off payment at a certain treatment day, or dollar amount, or reduce the cost of each procedure, thus reducing their bill.  Sometimes, of course, a negotiation occurs and all are satisfied.   Other times a lawsuit is involved.

In New England Sports Therapy v. MetLife Auto and Home, the Appellate Division said that a medical provider must “prove the reasonableness of any expense for which the claimant seeks PIP reimbursement, and entitles the claimant to a full recovery for those expenses found reasonable.”  Thus, the Court simply found that there was “ambiguities in the wording of the trial judge’s findings” so that the case must be remanded, or sent down, back to the Taunton Trial Court, for a new trial.  Were the bills reasonable but not fair?  The case will be retried, and perhaps appealed.  

What Can Victims of Motor Vehicles Do To Be Sure Their Medical Bills Are Paid?

 It is important to work with professionals who have your best interest as their interest.   Working with an experienced personal injury lawyer who has dealt with the antics of Massachusetts motor vehicle insurers, will insure that you are ready to take the offensive when necessary.  Working with medical providers who are honest and trustworthy and providing proper care, and billing fairly, is important as well.

Of significance, is staying on top of your case.  You should be sure your personal injury lawyer knows each and every medical provider you treat with, and any changes to your treatment or condition.  You should be sure that your provider knows what insurance companies to bill – billing is complicated, especially with PIP.

For our more information on PIP, see our blog article from earlier this year entitled How Does PIP Motor Vehicle Insurance Work   and our website page on PIP insurance .

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