The Basics
Every state has its own insurance laws, often referred to as the insurance code. Oregon law requires insurers doing business in Oregon to provide basic levels of coverage. One of these coverages is known as "Personal Injury Protection," or "PIP" for short. Here is a run down of the menu of benefits in your Oregon PIP coverage if you are involved in a collision.
It's "No Fault."
This means that the benefits are available regardless of who causes the collision. Even if you are at fault in causing an auto collision, you are entitled to PIP coverage. If another driver causes the collision, you are covered, but in many cases, your insurer is entitled to be reimbursed for the benefit it provides.
To be covered, you must be an "insured." This includes not only the person named on the policy, but also a driver who has permission to drive the vehicle. Passengers are covered, and in some cases, a pedestrian struck by an Oregon insured vehicle may have PIP coverage from the Oregon insured car.
Medical Insurance
Medical insurance must cover $15,000.00 for related and necessary medical care incurred within two years of the date of injury. Insurers may provide additional amounts of medical coverage.The statute borrows from Oregon's workers compensation medical fee payment schedule, so that all medical expenses are paid as if the treatment were for an on-the-job injury. This means there are usually no co-pays or deductibles with covered medical treatment.
The insurer must deny benefits within 60 calendar days after receiving a billing request from a medical provider. The medical provider must respond to written requests from the insurer within ten days during the first 50 calendar days after the injury.
The Insurer Can Deny Medical Coverage, But You Can Appeal
The insurer may question whether ongoing treatment is necessary, or related to the original injury. In these cases, the insurer can require that the insured attend an "independent medical examination." The examiners are not often true the independent, and may find that ongoing treatment is excessive or not related to the injuries caused in the motor vehicle collision. If the independent medical examiner finds that treatment is no longer necessary, the insurer can deny further treatment for coverage. However, the insured can appeal this denial by requesting arbitration, or filing a lawsuit directly against the insurer. In certain cases, the injured party may recover attorney fees if it prevails in court.
Sometimes, it may make better sense not to attend an independent medical examination. This is a decision that must be made on a case-by-case basis.
Other Medical Coverage
In serious injury claims, the personal injury protection or PIP medical coverage is often exhausted within days after the collision. In some cases, there being be another auto policy that will take over payment of medical expenses. This happens when there is more than one vehicle insured in a family household.
When the maximum coverage for PIP medical benefits is paid out, this is known as "exhaustion" of benefits. The next coverage in line to pay medical expenses is private health coverage, including any government-sponsored health plans like Medicare, Medicaid, or the Oregon Health Plan. The Oregon Health Plan also includes Coordinated Care Organizations, which behave like a Managed Care Organization.
Paying Back PIP or Other Health Insurers
If another driver caused your injury, your personal injury protection carrier is in the same legal position as you. You have suffered a personal loss because he suffered personal injury. Your insurer was forced to pay benefits, and it suffered a business loss. The Oregon personal injury protection statute allows your insurer to recover what it paid in medical or disability benefits. There are several ways your personal injury protection insurer can recover the benefits it paid. This is something you should pay attention to as he moved forward with the claim.
The same is true for other medical coverage including any private health plan, Medicare, Medicaid, Oregon Health Plan, or Coordinated Care Organizations. If you have a private health plan, the plan includes a provision that conditions payment for medical benefits on your promise to repay your health plan out of any settlement or recovery make against the at fault insurer. This is important to know because private health plans have the right to sue for recovery of benefits paid, and can get attorney fees in addition to the health benefits paid.
Government-sponsored health care plans rely on statutes that require you to report your claim against an at fault party. You then must report the settlement of any claim. After reporting claim settlement, the agency or a government contractor will contact you to make a demand for reimbursement. This is something not to ignore. For example, if Medicare is not reimbursed, it can sue you, your attorney, and the insurance company for triple the amount of the accident related medical benefits provided! There are also potential hefty fines. Do not ignore Medicare or any other government sponsored health plan.
Disability Benefits
Again, regardless of who caused the collision, if your insured under PIP coverage, you have a potential claim for wage replacement benefits, also known as "disability benefits." To qualify for benefits, you must prove that you were disabled from your work for at least fourteen consecutive days. The best proof of disability is verification from a treating physician. Many of the insurers will provide forms to the physician to complete and return to the insurance company. If you qualify for disability benefits, the insurer must provide 70% of your average weekly wage. There is a $3,000.00 On disability benefits, meaning that regardless of the extent of your lost income, you can recover no more than $3,000.00 in disability benefits for any given month.These benefits are not limited to the first two years after the injury, but instead run for a period of "52 weeks in the aggregate."
Essential Services: Managing a Household
If someone injured in a collision is not working outside of the house, and disability continues for 14 consecutive days, there is coverage for "essential services." This includes the value of housekeeping, and is limited to $30.00 per day, with a maximum benefit period of 52 weeks.
Funeral Benefits
If the collision causes a fatality, the estate is entitled to recover $5,000.00 in funeral expenses incurred within one year after the date of the collision. In cases involving passengers or innocent drivers, there may be a wrongful death claim, and the personal protection carrier may request reimbursement for this benefit as well.
Child Care
If the injured person is a parent of a child, and is hospitalized for at least 24 hours, the personal injury protection coverage allows a $25 per day benefit for child care, with the benefit payment beginning after the initial 24 hours of hospitalization, and to continue as long as the injured party is unable to return to work or perform essential services that they would have done even if they were not paid. The overall limit of benefits is $750.00.
PIP Coverage and the Underinsured Motorist Claim
If you suffer a serious injury, and the available coverage from the other driver's insurer is insufficient to compensate you for your injury, you may have an underinsured motorist claim. This coverage is also available if the other driver was uninsured. Recent changes in the law allow you to make a claim for compensation up to the amount of your uninsured/underinsured motorist coverage in addition to the amount of coverage and the at fault party's liability policy.
However, your insurer is entitled to a credit for the personal injury protection benefits it provided for your medical care, disability, or any other personal injury protection benefits. There are exceptions to this rule depending upon the amount of damage you can establish in an underinsured/uninsured motorist claim.
You Can Still Claim Actual Expenses Incurred
The amount he received from your personal injury protection carrier does not limit the claims you can assert against the at fault driver for your medical expenses or wage loss. For example, a physician may charge $150.00 for a doctor visit. The personal injury protection carrier may enjoy a discount of $50.00, and have to pay only $100.00 of the medical expense. Nonetheless, the medical expense incurred is $150.00, and you can make a claim for that amount if you end up filing a case in court.
The same is true for the wage loss or disability benefit. The personal injury protection carrier only pay 70% of your average weekly wage, but in reality, you may have lost more than 70% of your average weekly wage, and may have future lost earnings as well. Nothing the personal injury protection carrier pays you limit your ability to make a claim for the true loss of income, including future lost income, or future lost earning capacity.
Questions
Personal Injury Protection benefits and reimbursement of those benefits in serious injury claims can make for some issues, so if you have questions, contact us. We handle these issues every day.
