Detailed Answer
Rule 414 refers to a procedural provision in another jurisdiction and does not apply in Wisconsin. In Wisconsin, insurance adjusters must follow policy language, state statutes and the insurance code when reviewing and paying medical bills.
1. Policy Terms and PIP Benefits
Wisconsin’s Personal Injury Protection (PIP) coverage requires an insurer to pay “reasonable expenses incurred for necessary medical . . . services” under Wis. Stat. §632.70. An adjuster may request medical records, itemized bills and proof of payment. They cannot unilaterally apply a foreign rule to cut a covered expense unless the service falls outside your policy or the charge clearly exceeds what is reasonable.
2. Reasonable and Customary Charges
Insurers often compare a provider’s fee to local market rates. If a bill exceeds the usual and customary charge, the adjuster may dispute the excess amount. Disagreements typically trigger a peer review or utilization review rather than a fixed statutory rule.
3. Unfair Claims Practices
Wisconsin Admin. Code Ins 6.20 prohibits unfair or deceptive claims settlement practices. An insurer that arbitrarily reduces medical bills without a valid, documented basis may violate these provisions. You can report suspected violations to the Office of the Commissioner of Insurance.
4. Court Process and Discovery
In Wisconsin civil litigation, parties follow the Discovery Code (Wis. Stat. ch. 804). There is no “Rule 414” in Wisconsin. Instead, expert disclosures and requests for production occur under Wis. Stat. §§804.01–804.13. Adjusters cannot rely on an out-of-state court rule to justify reducing your bills during litigation.
Key Takeaway: Rule 414 does not govern insurance bill adjustments in Wisconsin. Adjusters must abide by your policy terms, Wis. Stat. §632.70, and the insurance code. If an adjuster proposes a reduction, they must document a valid reason such as noncoverage or unreasonable charges.
Disclaimer: This article is for informational purposes only and does not constitute legal advice. Always consult a qualified attorney for guidance tailored to your situation.
Helpful Hints
- Collect and organize all itemized bills, receipts and treatment records.
- Review your insurance policy’s medical payment and PIP provisions carefully.
- Request a written explanation from the adjuster for any proposed reduction.
- Consider an independent billing audit or utilization review to challenge high charges.
- If you suspect bad-faith practices, file a complaint with the Office of the Commissioner of Insurance.