Can an Insurance Adjuster Reduce My Medical Bills Because of Rule 414 in North Carolina?

Disclaimer: This article is for educational purposes only and does not constitute legal advice. Consult a qualified attorney for advice specific to your situation.

Detailed Answer

North Carolina’s Rule 414 governs how adjusters estimate and negotiate repair costs for auto claims in that state. However, Rule 414 has no force or effect in Oregon. If you’re insured or injured in Oregon, state law and your policy terms, not North Carolina rules, control how medical bills are paid and, if disputed, resolved.

Oregon’s No-Fault (PIP) Benefits

• Under ORS 742.466–742.468, Oregon drivers carry Personal Injury Protection (PIP) benefits. These cover medical expenses regardless of fault.
• PIP benefits are payable at 100% of “usual, customary and reasonable” charges. Insurers may request itemized statements or independent bill audits, but may not unilaterally reduce bills below that standard without supporting documentation. (ORS 742.468)
• If the insurer questions the reasonableness of a charge, they must notify you or your provider, and you may dispute the reduction through mediation or by filing a complaint with the Oregon Division of Financial Regulation.

Oregon Tort Claims (At-Fault) Medical Bills

• In an at-fault personal injury claim, your medical provider or you submit bills to the at-fault party’s liability insurer.
• Insurers often pay based on negotiated contract rates with providers, or subject to an agreed usual, customary and reasonable (UCR) fee schedule (such as Medicare rates plus a percentage).
• Absent a contract or fee schedule, the insurer must approve reasonable and necessary charges. If they refuse, you or your provider can demand appraisal or pursue a lawsuit for the full billed amount. See ORS 31.610–31.690 (hospital lien statutes) for lien rights against judgments. (ORS 31.610)

Adjuster Authority in Oregon

Insurance adjusters in Oregon must comply with state regulations (OAR 836-006) on claim handling and fair practices. They cannot apply North Carolina rules or arbitrarily slash your medical bills. Any proposed reduction must be supported by Oregon law, your policy’s terms, or an independent billing review.

Helpful Hints

• Review your insurance policy’s PIP or liability provisions. Know your coverage limits and deductibles.
• Ask for a full explanation in writing if an insurer proposes to reduce your bill. Request the legal or factual basis.
• Keep detailed medical records and itemized bills. Accurate documentation strengthens disputes.
• If necessary, file a complaint with the Oregon Division of Financial Regulation: dfr.oregon.gov.
• Consider talking to a personal injury attorney if your claim involves large medical expenses or a serious dispute.