Disclaimer
This article is for informational purposes only and does not constitute legal advice. Consult a qualified attorney to address your specific situation.
Detailed Answer
In South Dakota, there is no “Rule 414” that governs an insurance adjuster’s ability to reduce medical bills. Instead, adjusters base payment on the policy terms and state statutes addressing medical payment coverage and no-fault benefits.
1. Medical Payments (MedPay) Coverage: If your auto policy includes MedPay, the insurer pays “actual expenses” for medical care up to the policy limit, regardless of fault. Under SDCL 58-11B-8, an insurer may review bills to ensure charges are reasonable and customary, but cannot unilaterally apply a statutory “bill-reduction rule.” SDCL 58-11B-8
2. No-Fault (PIP) Benefits: If you elect personal injury protection (PIP) under SDCL 58-17-87, your insurer covers medical expenses, lost wages, and related costs for you and passengers, again up to policy limits. The insurer may verify that charges do not exceed usual and customary rates but cannot invoke an NC rule. SDCL 58-17-87
3. Reasonable and Customary Charges: South Dakota law allows insurers to negotiate or challenge bills that exceed reasonable and customary (R&C) charges. Most insurers use a nationally recognized database or their in-network provider rates to determine R&C levels. If a provider’s charge exceeds R&C, the adjuster will ask the provider to accept the negotiated amount.
4. Provider Negotiation: South Dakota providers may agree to reduced payments via lien negotiations or by contracting with the insurer’s network. You can request an itemized bill and ask your adjuster to facilitate negotiations with your provider.
In summary, while South Dakota insurers may challenge or negotiate medical charges, there is no Rule 414. Adjusters rely on policy language, SDCL 58-11B-8 (MedPay), SDCL 58-17-87 (PIP), and R&C methodologies to limit payments.
Helpful Hints
- Review your policy’s MedPay and PIP limits before seeking treatment.
- Obtain an itemized medical bill and explanation of benefits (EOB) from your insurer.
- Ask the adjuster how they determine reasonable and customary rates.
- Consider in-network providers to avoid high out-of-network charges.
- If you disagree with a reduction, consult a South Dakota attorney experienced in insurance disputes.