Disclaimer: This article is for general informational purposes only and does not constitute legal advice. Consult a qualified attorney for guidance on your specific situation.
Detailed Answer
In Virginia, there is no counterpart to North Carolina’s Rule 414 that automatically allows an insurance adjuster to reduce your medical bills. Instead, adjusters must follow your policy terms, state statutes governing claims practices, and any provider agreements or liens.
1. Policy Terms Define Covered Expenses. Your insurance policy should detail which medical expenses it covers and any limits or fee schedules it uses. Some policies cap payment at a “usual, customary, and reasonable” (UCR) rate or a defined fee schedule. An adjuster can apply these terms when reviewing your bills, but cannot go beyond what the contract allows.
2. Unfair Claim Settlement Practices. Under Virginia Code § 38.2-510, insurers and adjusters must act in good faith and handle claims fairly. They cannot misrepresent policy provisions, undervalue covered expenses without justification, or unreasonably delay payment. Learn more about prohibited practices: Va. Code § 38.2-510.
3. Definition of an Adjuster. Virginia Code § 38.2-183 defines who may adjust claims in the Commonwealth. Adjusters must be licensed and comply with state regulations. They base payment decisions on policy language, billed charges, and any relevant statutes or case law. See the definition here: Va. Code § 38.2-183.
4. Medical Provider Liens. If a health care provider treats you after an accident and places a lien against a future insurance recovery, they rely on Virginia Code §§ 8.01-581.1 to 8.01-581.15. An insurer can negotiate with the provider to accept a reduced amount in full settlement of the lien, but cannot unilaterally impose reductions outside those negotiations. For more on liens, see: Va. Code § 8.01-581.1.
5. Disputing an Adjuster’s Decision. If you believe an adjuster has improperly reduced or denied payment of medical bills, you may:
- Review your policy for definitions of covered expenses and limitations.
- Request a detailed explanation of benefits (EOB) from the insurer.
- Provide documentation of usual and customary charges for comparable services in your area.
- File a complaint with the Virginia Bureau of Insurance: www.scc.virginia.gov/pages/Insurance.
Helpful Hints
- Carefully read the “medical expenses” or “medpay” section of your policy.
- Ask the provider if they participate in a preferred provider organization (PPO) with your insurer.
- Keep copies of all bills, EOBs, and correspondence with the insurer.
- Obtain comparative rate data to challenge any “unreasonable” charge adjustments.
- Consider consulting a personal injury attorney if you face significant denials or reductions.