Detailed Answer
When an insurance adjuster disputes that your medical treatment relates to a Pennsylvania car accident, follow these steps to protect your right to benefits under Pennsylvania’s Motor Vehicle Financial Responsibility Law (MVFRL). This guide explains how to document causation, navigate insurer requests, and pursue dispute resolution.
1. Review Your PIP Coverage
Pennsylvania requires Personal Injury Protection (PIP) benefits under the MVFRL (75 Pa.C.S. § 1701 et seq.), covering at least $5,000 in medical expenses per accident. Review your policy’s terms and PIP limits. You can find the MVFRL statutes at 75 Pa.C.S. § 1701 et seq.
2. Gather Medical Records and Treating Physician Statements
Obtain complete medical records, billing statements, and a narrative letter from your treating physician explaining how each treatment relates to the accident. Detailed medical documentation establishes causation and necessity.
3. Submit a Written Demand to the Insurer
Send a formal demand letter by certified mail to your insurer, attaching:
- Medical records
- Physician narrative opinion
- Itemized bills
- Proof of payment or outstanding balances
4. Respond to Independent Medical Exam (IME) Requests
An insurer may request an IME under 75 Pa.C.S. § 1798. Schedule the exam promptly. If you believe the request is unreasonable, note timing, location, or wrong specialist, and explain your objections in writing.
5. Pursue Arbitration for PIP Disputes
If the insurer continues to deny or undervalue your claim, you can file for arbitration with the Pennsylvania Insurance Department under 31 Pa. Code Chapter 67. You must submit the arbitration request within 12 months of the disputed treatment (31 Pa. Code § 67.802). The arbitrator issues a binding decision on causation and benefits.
6. Consider Legal Action
If arbitration fails or your claim exceeds PIP limits, consult an attorney about filing a lawsuit against the at-fault driver or a declaratory judgment action against your insurer. An attorney can also advise on uninsured/underinsured motorist (UM/UIM) coverage.
Disclaimer: This article is for informational purposes only and does not constitute legal advice. Consult a qualified attorney for advice specific to your situation.
Helpful Hints
- Keep a detailed treatment log with dates, providers, and symptoms.
- Send all letters by certified mail with return receipt.
- Obtain an orthopedic or specialist opinion for complex injuries.
- Track all medical expenses, including therapy and prescriptions.
- Review your insurer’s denial letter carefully for grounds of dispute.
- Meet deadlines: PIP arbitration typically requires filing within 12 months.
- Explore mediation as an alternative to binding arbitration.