Can personal insurance deny payment for treatment

by nb926 » Sun Jul 10, 2011 01:11 am
Posts: 2
Joined: 10 Jul 2011

I have exhausted my PIP coverage in a MVA in which I was found NOT at fault. I sustained 2 disc herniations but do not want to have surgery. Will my personal health insurance pay for ongoing medical needs after I settle with the MVA case? Or can they deny payment because it was the result of an MVA?
My lawyer said that I should settle now (for the $25K)and file for further medical mgt w my own insurance. My outstanding bills and legal fees will leave me with nothing

Total Comments: 6

Posted: Sun Jul 10, 2011 01:48 am Post Subject:

They should not deny coverage... they are excess over your PIP but should kick on once its gone.

I'm guessing you don't have UIMBI.

I'm hoping your attorney is going to see about reducing or has already reduced your medical bills that PIP did not address.

This is certainly a case where having an attorney is not a good thing... when the other carrier is going to pay their policy limits anyway. Sorry to say.

Posted: Sun Jul 10, 2011 02:52 am Post Subject: your reply

so you mean that I would have had the same result w/o an attorney and thus have his fee in my own pocket? The insurance company offered lower amounts several times until my lawyer proceeded to file a case against them. My lawyer said that he would be requesting reduced bills from the MD's and therapy whom I have been seeing.
As long as my BCBS ins will cover further treatment, I will be happy.
Thanks

Posted: Sun Jul 10, 2011 03:58 am Post Subject:

so you mean that I would have had the same result w/o an attorney and thus have his fee in my own pocket? The insurance company offered lower amounts several times until my lawyer proceeded to file a case against them.



You mentioned that your medical bills exceed the $25,000 policy limit, no? If your medical bills exceed this amount, I can't see why the carrier would not be offering up their limits. But if your attorney needed to file suit then the offer would probably have been less w/o an attorney. But here is the question...was their offer more then $15,000? This is what you will be getting after the attorney takes his 40%.

This is of course all hind sight. Perhaps the attorney was the way to go.

Posted: Sun Jul 10, 2011 11:45 am Post Subject:

Their offer never exceeded $7000 until the attorney began the suit. Now they are offering the limit (25K). He says that after all is said and done and bills are reduced, I should have about 10k. My major concern is that I am still having pain (cervical) and still going for facet injections about 3x/yr as well s therapy. Will I have to tell BCBS that I need tretment due to the MVA, and can they reject paying? The money is secondary, I want to have ongoing treatment as I am still in pain.
Is there any benefit to refusing to sign off yet? I trust my lawyer and believe that if there is more money for HIM in it, he would not have advised me to settle. Thanks

Posted: Sun Jul 10, 2011 02:18 pm Post Subject:

I was under the impression that your medical bills were already in excess of $25,000. As they are not, what I mention does not apply.

Your health carrier should pay for your medical expenses. They are secondary to your PIP but your PIP is exhausted (so they are not primary). Your health carrier inherits your right of recovery against the at fault party but since you'd be signing a release, your heath carrier can no longer collect from that party or their insurance company. This is fine, your health carrier can still pay your medical bills. I see no reason not to settle now... as if you don't and your health carrier pays for medical expenses then they could ask to be paid back out of that $25k settlement. Better that you settle with the other person's carrier, pocket your money and _then_ have your health carrier start paying. This way they can't lay claim to any of that $25k. If the other carrier is offering up their policy limits now then waiting it not going to change what they are going to offer... you will just owe your attorney more for his expenses. I'm guessing the other person does not have any assets worth going after. If not, that $25k is not going to turn into anything more.

Here are the parts of your post that don't seem to be correct:

My outstanding bills and legal fees will leave me with nothing

He says that after all is said and done and bills are reduced, I should have about 10k.



Either you are walking away with nothing or you are walking away with $10k.

Posted: Sun Jul 10, 2011 08:10 pm Post Subject:

so you mean that I would have had the same result w/o an attorney and thus have his fee in my own pocket?



If you have legitimate medical expenses that have reached as high as $25,000 or more, then the answer is yes. It doesn't matter what the insurance company was "offering", they are responsible for 100% of your covered loss. An attorney can't do better than that as far as PIP payments are concerned. Simply knowing your rights and being persistent would have put the money in your pocket.

If you have total accident-related losses (aside from the property damage to your vehicle) far in excess of the PIP limit, then you may have the basis for a civil suit to collect the excess loss you have incurred. For that, to argue your case effectively, you might need an attorney. Those losses would be paid from the at fault party's liability coverage (if they have any) . . . or from their pocket if not insured.

Generally, most of us with experience would only recommend seeking legal counsel in a claims situation when you have come to an impasse with the insurance company, and no one is willing to make any concessions.

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