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

Detailed Answer

Disclaimer: This article is for educational purposes only and does not constitute legal advice.

You live in Massachusetts, so North Carolina’s Rule 414 does not apply to your insurance claim. Each state sets its own rules for how insurers handle medical bills after an accident. Massachusetts requires automobile insurers to follow the state’s no-fault (personal injury protection, or PIP) rules under G.L. c. 90, § 34M, and promulgated regulations at 108 CMR 10.00.

Under Massachusetts law:

• Insurers must pay “reasonable and necessary” medical expenses up to the PIP policy limit. See G.L. c. 90, § 34M (https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXIV/Chapter90/Section34M).
• “Reasonable and necessary” is defined by reference to usual and customary charges in your geographic area, consistent with the Division of Insurance’s fee schedule (108 CMR 10.00).
• An adjuster may challenge a bill as unreasonable, but must explain why and offer documentation or cite the fee guidelines. They cannot unilaterally apply an out-of-state rule.
• If you disagree, you may request an internal review or file a complaint with the Massachusetts Division of Insurance under G.L. c. 176D, § 3 (unfair claim settlement practices).

Why North Carolina Rule 414 Doesn’t Apply

North Carolina Rule 414 governs how adjusters in that state evaluate medical expenses under North Carolina’s Uninsured/Underinsured Motorist regulations (NCAC 04 – 05 – 020(b)(4)). Massachusetts has its own rules, so your Massachusetts-licensed insurer must follow MA law, not NC regulations.

When an Adjuster Can Reduce Medical Bills in Massachusetts

• If the bill exceeds customary charges within the region.
• If services are not medically necessary for treating your injuries.
• If the provider failed to document the treatment or provide records.

How to Challenge a Reduction

• Ask for a written explanation citing specific fee guidelines.
• Obtain comparative billing data from similar providers in your area.
• File a claim settlement complaint with the Massachusetts Division of Insurance: https://www.mass.gov/servicedetails/auto-insurance-consumer-complaints.

Helpful Hints

• Review your PIP policy declarations and limits carefully.
• Keep all medical records, bills, and correspondence in one file.
• Ask your health care provider if they’ll appeal reductions on your behalf.
• Consider hiring a consumer advocate or attorney if the dispute exceeds your policy limit.
• Document every call, email, and letter exchange with your insurer.