Detailed Answer
This FAQ explains your options when a New Jersey auto insurer refuses to link your medical treatment to a crash. Under New Jersey’s Personal Injury Protection (PIP) law, insurers must pay up to $250,000 for reasonable and necessary medical expenses arising from an automobile accident (see N.J.S.A. 39:6A-4). When an adjuster disputes causation, follow these steps.
1. Review Your PIP Coverage and Policy Language
Start by reading your auto insurance policy. Look for the PIP section that defines compensable medical treatment and causation requirements. Confirm the provider bills and dates of service fall within the PIP timelines.
2. Gather Comprehensive Medical Documentation
- Obtain detailed medical records from all treating providers, including emergency room, primary care, specialists, and rehabilitation notes.
- Request a letter of medical necessity clearly linking each treatment to the crash.
- Include diagnostic imaging (X-rays, MRIs, CT scans) and test results that show accident-related injuries.
3. Send a Formal Rebuttal to the Adjuster
Submit a written response outlining why treatment qualifies under PIP. Attach the medical necessity letters, records, and itemized bills. Send it via certified mail so you have proof of receipt.
4. Request an Independent Medical Examination (IME)
If the insurer suspects exaggeration or unrelated conditions, they may require an IME. Attend the exam but prepare by bringing all prior records and a list of ongoing symptoms.
5. File a PIP Arbitration or Department of Banking and Insurance Complaint
If the insurer still denies your claim, you can:
- Submit a PIP arbitration demand under N.J. DOBI PIP rules.
- File a written complaint with the New Jersey Department of Banking and Insurance (DOBI Consumer Inquiry).
6. Consider Consulting a Motor Vehicle Accident Attorney
While you can handle PIP disputes yourself, an attorney can:
- Explain your coverage and rights under N.J.S.A. 39:6A-4.
- Represent you in arbitration or court if needed.
- Negotiate with the insurer for maximum allowable benefits.
Disclaimer
This article provides general information on New Jersey law. It does not constitute legal advice. Consult a licensed attorney for guidance tailored to your situation.
Helpful Hints
- Keep a copy of every bill, record, and letter you send or receive.
- Document all accident-related expenses, including mileage to medical appointments.
- Follow up promptly if the insurer requests additional information.
- Note all communication dates and adjuster names in a dedicated accident log.
- Ask your healthcare provider to use the New Jersey Official Medical Fee Schedule (OMFS) when billing.