Understanding Your Medical Bills and Insurance Adjusters in New Jersey
Disclaimer: This article is for educational purposes only and does not constitute legal advice. Consult a qualified attorney for advice on your specific situation.
Detailed Answer
Many New Jersey residents wonder if an insurance adjuster can slash their medical bills simply by invoking a procedural rule like North Carolina’s Rule 414. In New Jersey, no such rule exists to let adjusters unilaterally reduce your medical charges. Instead, New Jersey’s Personal Injury Protection (PIP) system and related statutes set clear guidelines for payment and reasonable disputes.
1. No “Rule 414” in New Jersey
“Rule 414” is a North Carolina evidence rule concerning expert testimony. New Jersey does not have a counterpart that governs how insurers calculate or reduce medical bills. Any reduction of medical charges must follow New Jersey law, not an out-of-state procedural rule.
2. PIP Reimbursement Limits under NJAC
Under New Jersey’s Personal Injury Protection law, PIP insurers pay medical providers according to a fee schedule known as the Health Care Provider Reimbursement Manual. This schedule is established in N.J.A.C. 11:3-4.8. Insurers must reimburse up to the maximum allowable amount for covered medical services.
- Link to Manual: N.J.A.C. 11:3-4.8 Health Care Provider Reimbursement Manual.
3. Disputing Unreasonable or Unnecessary Charges
Insurers may challenge a medical bill if they believe treatments are unreasonable or not medically necessary. Under N.J. Rev. Stat. § 39:6A-4(l), an insurer has 30 days from receipt of a properly documented claim to either pay or dispute charges. If the insurer timely disputes, the dispute process governs resolution. If no dispute is filed within 30 days, the insurer must pay the full amount due plus interest.
4. No Arbitrary Reductions
An insurance adjuster cannot simply decide to reduce your bill by a flat percentage or invoke an unrelated procedural rule. All reductions must comply with the PIP fee schedule or a valid dispute process. Any improper reduction may give rise to a bad faith claim under N.J. Rev. Stat. § 17:29B-4, which prohibits unreasonable denial of first-party claims.
Helpful Hints
- Review your insurer’s Explanation of Benefits (EOB) carefully. It must state the reason for any partial payment or denial.
- Know the PIP 30-day rule: if you don’t receive a dispute notice within 30 days, your insurer must pay.
- Consult the NJ PIP Fee Schedule to compare billed charges vs. allowable amounts.
- If your insurer disputes a bill, you can request an independent medical review or file a petition with the New Jersey Department of Banking and Insurance.
- Document all communications with your insurer in writing and keep copies of all bills and medical records.