RE: PIP Application- Attorney Question

[Guest guest]

The proof of loss statute is thinking of is probably the UM statute at 742.504(5)(, which requires a written proof of claim, and if the insurer furnishes forms within 15 days of notice of the claim, the insurer can require proof of claim on those forms. In a PIP case, can the PIP insurer require proof of loss on their form? Probably not. By all means, look at the policy and see if it allows them to compel proof on their form. If not, they’re sunk because they cannot insist upon anything not in the policy. If the policy does say they can require their form, then they may argue about non-cooperation under the policy. A non-cooperation defense requires a showing that they looked for their insured and that they are prejudiced by the non-cooperation. Look to see what’s on their form. If yours and theirs have the same info, I think they’re sunk because they cannot claim prejudice (aside from having to pay a claim they agreed to pay…). If the forms have substantially the same info which allows the insurer to investigate the claim—e.g. date of loss, vehicle involved, statements about not on the job, the providers seen—then you can argue no prejudice to the insurer. The adjuster will want to see all the records and bills, and depending on your paperwork you may be able to provide that to them to get your bills paid. T. Hill, PC520 SW Sixth Avenue, Suite 1250Portland, OR 97204(503) 227-4330chill@...http://www.portlandinjurylaw.com From: [mailto: ] On Behalf Of Sent: Tuesday, December 13, 2011 6:33 PM Cluen; Subject: RE: PIP Application- Attorney Question I admit to not being able to locate the statutory answer. Perhaps a more adept attorney on the list (or one less tired than me) could locate it. Somewhere in the general liability insurance statutes or the motor vehicle insurance statutes, or the pip or uninsured motorist statutes, there's a reference to an insurer being permitted to demand proof of loss on a form provided to the insured by the insurer, if the form is sent to the insured within so many days. But I can't find that reference, and I can't remember if it applied to PIP, uninsured motorist, or to all claims. But I'm kind of suffering from some temporary dyslexia at the moment. You should start by trying to review the actual policy language contained within the policy itself. If there's a clause requiring an insured to submit an Application for Benefits on the form supplied by the insurer, then that might help identify the precise statute upon which they are relying. You might ask them to identify both the clause in their contract as well as the Oregon Statute upon which they are relying, and who knows, they might actually tell you. Even if the form is not the one supplied by the insurer, if it's virtually identical, then you might be able to argue that it is the form supplied by the insurer. You also might simply call the insurer and explain the situation, that you're not trying to pull a fast one, but that the patient is m.i.a. However, you're next problem may be that if the insured is m.i.a., I think it would be hard to argue if the insurer then claimed that they needed to take the statement of the insured before sending anyone a dime, just to make sure that it really was a legitimate claim, and if the insured hasn't sent in the application sent to the insured, then (I hate to concede it), the insurer might have a very reasonable question as to whether it is a legitimate claim or not (i.e., is the patient truly the insured?). This is a tough one. PIP is first party coverage. The insurer owes benefits, if at all, to the insured, not you. While coverage is mandatory, I have a hunch that insurers pay medical bills directly to the providers as a convenience to the insureds. I think an insurer could (and as you know, some have) paid money for treatment directly to the insured, not the doctor. I've heard complaints that some insurers do this just to spite and punish chiropractors that they don't like. But they do it, I think they unfortunately can lawfully do it, and the bottom line is that the only reason that an insurer has to pay you is that the insured owes you, and the debt is covered by the policy. Now you've prudently obtained a signed authorization from the patient authorizing payment to you. However, I don't think the language of your side-contract sounds like it constitutes an actual assignment or conveyance to you of the patient's right to receive reimbursement under the policy. It might just say that you are authorized to accept payment. If it doesn't say that you actually are the sole owner of the right to receive payment, then if that insurer truly wishes to jerk you around, they might unfortunately have a leg to stand on. Sorry to be the bearer of possibly bad news. Again, the bottom line is that the patient owes you the debt, not the insurer. Any obligation the insurer has flows through the insured. And that's a general rule that applies to all insurance policies, except perhaps the first 25k of liability coverage which, as a matter of public policy, is for the legal benefit of the injured party. And if the patient is not cooperating with the insurer (and obviously not cooperating with you), then that's a problem, and it's not just the insurer's problem, it's unfortuantely yours as well. I don't know that there's a black and white answer. G. Gatti, Gatti, Maier, Sayer, Thayer, & Associates1781 Liberty St. SESalem, OR 973021-(800) 289-3443 msmith@... From: [mailto: ] On Behalf Of CluenSent: Tuesday, December 13, 2011 5:21 PM Subject: PIP Application- Attorney Question Hey All! I have a generic PIP application that I have all the patients fill out in case we can't get in touch with them and they don't fill out the PIP app sent by their carrier. I've used it to get paid many times. I wanted to know if an insurance company has the right to not accept a generic version because Amica is refusing to pay on a patient that came in a few times and is now MIA. Lastly, my lien, limited POA, and assignment allow our office to sign and endorse checks and claim forms: " I give Dr. Cluen or his assignees power of attorney to receive, endorse, deposit, and cash any checks or claim forms on my behalf whether they are made out to me, the doctor, or the doctor and me jointly in order to pay in full any amount owe the doctor (Limited Power of Attorney) " Can I sign and fill out the PIP form through POA? I've never had to do this, but there is always a first time. Thanks, Cluen, DCAuto & Work Injury Center3311 NE MLK Blvd. Suite 202Portland, OR 97212503-282-4878