The Definitive Guide to Personal Injury Protection: (PIP Insurance Claims + Benefits Explained Simply)

Learn how PIP claims after an accident work in "no fault" car insurance states.

Whether you are purchasing PIP car insurance for the first time or making a PIP Claim the information below will help you.

Personal Injury Protection is complex and varies greatly by policy and State requirements. This information, tips and processes will make your purchasing & post-accident choices much easier.

We never know when an auto-accident will happen - the benefits of insurance coverage: supposedly you are protected.

 

"Each day in the United States, approximately 9 people are killed and more than 1,000 injured in crashes that are reported to involve a distracted driver." - CDC

What is PIP? (Why do you need it?)

after a car wreck

What is Personal Injury Protection (No-Fault insurance)?

  • What is PIP? Personal Injury Protection is an extension of auto-insurance coverage that pays medical expenses due to a car accident.
  • Who is covered? PIP “No-fault” insurance provides medical coverage you, anyone on your policy or passengers in your car.
  • What does it cover? PIP Insurance is used for people, not property. This additional insurance can cover medical expenses, lost wages, household expenses, child case and more.
  • How long does it last? PIP Claims will cover your medical care and other expenses for an extended period of time after the accident. This varies by State. For Example in Massachusetts PIP claims can be made up to two years after the accident. (Part 1, Title XIV, Chapter 90, Section 34)
  • Quick PIP Tip: Accident victims should know that PIP benefits will come directly from their own Insurance provider. Even if you are completely innocent in a crash, you will deal directly with your own Insurance provider when filing a PIP claim.
  • Other PIP info: There are minimum PIP coverage requirements set by States. Insurance companies offer auto-insurance plans above and beyond those requirements.
  • Fault States: PIP insurance is not available everywhere. In “Fault” States insurers offer similar plans called Med-Pay Coverage. More on that in the sections below.

 

Have You Or Someone You Love Need a Car Accident Lawyer?

Why do you need PIP?

  • Motorists need to have PIP coverage if it is required by their State.
  • Drivers need PIP to protect themselves, their family and their passengers.

Currently 15 States require PIP insurance coverage:
Florida, Kentucky, Pennsylvania, New York, Maryland, Delaware, New Jersey, Massachusetts, Michigan, Minnesota, North Dakota, Kansas, Utah, Oregon & Hawaii

Your PIP insurance will cover medical expenses for the policy holder, all those listed on the policy and any other passengers in the vehicle that may not fully be covered by health insurance. The benefits of PIP are meant to cover less serious injuries, not catastrophic injuries or fatalities.

No-Fault Laws Explained

What is "No-Fault"?

A common misconception of “No-fault” laws is that no one is held responsible for an automobile crash. This is incorrect.

Someone is always at-fault for violating the rules of the road. Fault based rules will still be applied to an accident. For more information a comprehensive overview on how fault is determined in a car accident is available here.

No Fault laws ensure that injured victims of a collision receive benefits and medical coverage directly from their insurance company, regardless of fault.

No-Fault Laws do not require a determination of who was at-fault (responsibility) for an accident. This allows for faster payment of medical expenses since litigation and judgment are not required.

All first party benefits and medical expenses can be covered under their own PIP insurance when PIP claims are made.

Why do some States have “No-Fault Laws?

States enact No-Fault Laws for two reasons:

  1. To lessen the burden on the State’s court system. PIP Claims are settled directly with the policyholder’s insurance company regardless of fault. Minor cases do not go to trial.
  2. Medical claims are paid faster as a result. By avoiding litigation, claimants can receive insurance payouts for medical and other expenses faster. (TIP: Be careful here. Most Insurance companies try to pay the minimum)

What is Covered by PIP? (4 Major Benefits)

 

The 4 Major Benefits of PIP Coverage are:

  1. Medical Expenses
  2. Loss of Wages
  3. Replacement Services
  4. Vehicle Mileage

Specific insurance policy coverage limits will apply to you. Understanding your policy’s coverage is important. Other damages that which may be covered can include Attendant Care, Vehicle Modification, Home Modification or Funeral Expenses.

 

Medical expenses (What types are paid of?)
  • PIP Insurance will cover some or all Medical Treatments. This includes Doctor’s Visits, Hospitalization, Physical Therapy and Medical Diagnostics that you need after a car accident.
  • PIP will cover things like health insurance copays, deductibles and other out-of-pocket medical expenses.
  • Some plans cover dental care, chiropractic services and ambulance fees
  • Medicare, Medicaid, ERISA plan or other public health plans may receive large benefits.
Loss of Wages (How much it covered?)
  • PIP will also cover a percentage of lost wages if you have to miss work. When filing your PIP claim a “Wage and Salary Verification” form will need to be included of this benefit. (TIP: Your employer will need to complete this form and it will include 10-14 weeks of salary)
  • How much is covered depends on your additional PIP insurance policy and the State you live in. Below are two examples of the State benefits required.
    • Michigan - In Michigan up to 85% of lost wages will be covered for up to 3 years after the accident. MCL 500.3107 (1)(b)
    • Florida - In Florida up to 60% of wages will be covered. (Fla.Stat. 627.736)
    • (TIP) What happens to the rest of your lost wages not covered by PIP? This is can be part of your claim against the At-Fault driver. Remember that “No-Fault” does not mean no one is at fault. If a driver is found negligent they can be held responsible for additional damages. Getting proper legal advice is important for this situation.
Replacement Services (Help from others)
  • Replacement Services are expenses from family or non-family members that provide services to an injured person. The need for these services must due to the accident.
  • Examples include child care, cleaning services, lawn care and meal preparation.
Vehicle Mileage for Medical trips
  • Reimbursement for transportation to and from doctors’ offices, hospital and rehabilitation are covered by PIP. Taxi, Uber and ride share costs will also be covered if you can’t drive as a result of the accident.
  • Keep a detailed record of all your mileage expenses. These will be submitted with your medical bills as part of your PIP Claim.
crashed in parking lot

How a PIP Claim Works?

Once you’ve receive medical treatment the first thing to do is review your Insurance Policy. Ensure you have additional PIP coverage and know what your benefits are. PIP benefits are paid after health insurance benefits are applied.

(TIP: Know your PIP Claim deductible and your Health Insurance coverage out-of-pocket expenses)

After the accident you need to contact your insurance company. Don’t wait! States have strict limits on the time to file a claim. In Florida you have two weeks. After that your PIP claim will be rejected.

Be open with your Insurance company and let them know what happened. You are required to cooperate with them in order to receive you PIP benefits.

IMPORTANT TIP: You are not required to cooperate with 3rd Party Insurers. Contact a PIP claims attorney who can negotiate on your behalf so you don't miss out on entitled benefits.

Once the insurance company is informed of your PIP Claim you will receive various forms to complete. Here are a list of some forms to expect:

  • Personal Injury Protection Benefit Application - This will request information about the accident, your injuries, location of medical care your received and any lost wages.
  • HIPAA Release Form - This will allow the insurer to receive your medical records and bills from health care providers. The information allows insurers to arrange for payment of these medical expenses
  • Wage and Salary form - This allows insurers to contact employers for the release of income. Your insurer follow-ups with your employer directly with a Wage and Salary Verification process.

TIP: Complete the forms quickly and honestly. You are required to cooperate with your insurer. Keep a copy of all completed forms for your records.

What happens next?

Before moving forward, if you haven't retained counsel with a qualified car accident attorney, it's strongly recommended you do so now. At minimum seek a free consultation to review your claim to make sure the insurers are playing fair.

A variety of things may happen depending on your specific PIP Claim.

  1. You insurance company can request an Independent Medical Examination (IME) during any point of the claims process. This is an examination by an independent Doctor who will decide if your medical condition and treatments to this point have been necessary. They will also determine if additional medical treatments are needed. (TIP: You must comply. Failure to show-up for the examination will result in termination of you claim.
  2. Sworn statements, testimony or depositions concerning the accident may be required. Known as examination under oath (EUO). If EUO is require you should seek advice from a qualified accident or personal injury lawyer.
  3. The insurer will be required to pay your claim. Most States mandate this payment is made within 30 days. However, insurance companies have an extended period to review your PIP claim for fraud. Normally 60 Days. If you receive notice of claim review you should contact an attorney.
  4. PIP Benefits are paid-out but do not completely cover your out-of-pocket expense. If another driver has been negligent (cited for speeding or distracted driving) you may be able to file a lawsuit against their insurance company for compensation. Attorneys will offer free initial consultations about accident cases.

Third Party Claims: What is Subrogation?

PIP is designed to pay medical expenses quickly. This is done so accident victims can receive needed payments and other benefits right away. However, PIP payouts are subject to third party settlements and subrogation.

What is Subrogation?
The California Department of Insurance (CA.Gov) states subrogation “is the right of the insurance company to recover from a third party the amount of damages it paid to you”. This means that insurance companies can work together to recover benefits they paid out to their customers.

An example of how Subrogation works with PIP?

Jane is injured in an accident. She immediately files a PIP claim for benefits with her Insurance company. Her insurer pays out $6,000 in PIP benefits because of the State’s requirements. Then two months later she files a claim against the other insured party. A benefit of $17,000 is awarded do to negligent driving.

At this point your insurer can seek reimbursement for the $6,000 in PIP benefit it paid. Rather than having you pay your insurer back the two insurance companies will subrogate (work together) on their own.

In that case the 3rd Party Insurer (that awarded your case $17,000) will make an offer of $11,000 because they know you already received $6,000 in PIP Benefits.

(TIP: Insurance companies have vast experience working together on benefit cases. Accident victims should have proper legal representation on their side as well by consulting an attorney for free)

Med-Pay vs. PIP Coverage (Differences)

broken-windshield-from-accident

What is Med Pay Coverage?

Med Pay is an extension of your car insurance that covers medical, surgical, dental and other necessary and reasonable treatments because of a vehicle accident.

  • Coverage can include:
    • Doctor visits & Hospitalization
    • Medical Diagnostics
    • Nursing Care
    • Prosthesis
    • Ambulance Fees

Med-Pay coverage is not always needed. Private health insurance plans, HMOs may offer the same cover. Med-Pay is normally offered by insurance companies in States where PIP supplemental insurance is not required.

(TIP: Med Pay is not a replacement for health insurance. It only provides benefits for injuries sustained from an automobile accident.)

What is the difference between Med Pay and PIP?

PIP Plans offer the same medical coverage as Med Pay. However, PIP offers additional benefits not offered under Med Pay plans.

  • PIP offers more cover including:
    • Lost Wages
    • Rehabilitation expenses
    • Psychiatric exams
    • Occupational therapy
    • Death benefits
    • Recoverable services (non-medical)
    • Vehicle Mileage

PIP coverage can be mandatory in your State or optional. When it is optional your insurance provider may be required to have you accept or reject the cover. You can not have both Med Pay and PIP coverage.

(TIP: When deciding on additional coverage it is important to understand your health insurance costs and benefits in case of an accident.)

How does a PIP Claim work? (8 Simple Steps to Maximize Claim Benefits)

Claim Process Overview

    After an accident you will need to deal directly with your Insurance Provider. Here are the 8 Steps to expect during the process.

    Step 1 - Complete Steps 2-4 right away.
    Step 2 - Understand your policy coverage before calling
    Step 3 - Good record keeping of expenses
    Step 4 - Contact your Insurance company and cooperate
    Step 5 - Dealing with third party Insurers
    Step 6 - Independent Medical Exam (IME)
    Step 7 - Receive and Complete Insurance Forms
    Step 8 - Give official statements and oaths

Step #1 - Complete Steps 2-4 right away. (Day after accident)

    Step 1 - Complete Steps 2-4 right away. (Day after accident)

    States have strict time limits to file PIP Claims. Don't delay. Complete steps 2-4 right away.

    This was given its own step (Step 1) because it is very important.

    For example in Florida you only have 14 days after an accident to apply for your PIP benefits.

    If you are in the hospital have a friend or loved one assist you with steps 2-4. They might even get paid for it! Follow below.

Step #2 - Understand your policy. (Day 2)

    Before contacting your insurance company completely review your additional insurance PIP coverage.

    1. Download and read your policy directly from your Insurer
    2. Grab a pen and paper to make notes as you read
    3. Make notes on your PIP deductible.
    4. Write down PIP benefits your covered for and need
    5. Know what your Health Insurance will cover
    6. List of questions for your Insurer

    TIP - Don’t wait. Time is important. You need to contact your Insurer to report the accident as soon as possible.

Step #3 - Record Keeping

    Keep all your Medical Bills, Mileage, Police reports, anything that applies to the accident. You should:

    1. Get a Folder and keep all original documents. Name the file “My PIP Claim”.
    2. Make a copy all records
    3. Request copies of medical bill and records from the accident.
    4. Scan documents to digital copies so you have a back-up.
    5. Keep track of:
      1. Any mileage used by anyone helping you
      2. Ambulance fees
Step #4 - Contact your Insurance Company

    Now it’s time to call your insurance company. You are required to cooperate with your Insurer for a PIP Claims.

    1. Your insurance provider will need all your information.
    2. Tell them everything about the accident
    3. Make notes of your insurers recommendations
    4. Get all your questions answered
    5. Make sure to write down your PIP Claim number/ID
Step 5 - 3rd Party Claims (Subrogation)

    While you are required to cooperate with your Insurer, you are not required to cooperated with a 3rd Party’s insurance company.

    1. You may be eligible for 3rd Party insurer benefits
Step 6 - Independent Medical Exam (IME)

    If the insurance company requests you get an independent medical exam (IME) you should, as you are required pursuant of No Fault statutes to submit to such an examination. Refusal to go to an IME could result in the loss of your PIP benefits under the provision.

    The assessment of the "so-called" independent medical examiners will be used to determine treatments as necessary or "unnecessary". Injury victims who have had their benefits cut off and treatments deemed "unnecessary" by their IME should consult with their personal injury attorney immediately.

    The insurance companies will fight to reduce what they pay out, don't expect them to play fair.

Step 7 - Review Denied or Reduced Explanation of Benefits

    Discrepancies in Explanation of Benefits line items being listed as $0, or allowed amount reductions are indicators of a potential issue with charges not being paid. Your attorney will need the provided Assignment of Benefits (AOB) document to proceed.  If the IME examination suspends benefits, reduces benefits below what is expected, this should be shared with your law firm.

    The pre-suit process begins wth a demand letter to the insurance company disputing the claim status and provides 30 days for action to be taken. Failure to remedy the demands can lead to litigation.

Step 8 - PIP Litigation

    If your demand letter is ignored or the response fails to satisfy, you may decide to take legal action. If so your PIP attorney will file suit with the appropriate court and begin the legal dispute process in pursuit of a resolution.

    * Note: While you are required to cooperate with your Insurer, you are not required to cooperated with a 3rd Party’s insurance company. You may be eligible for 3rd Party insurer benefits. Your lawyer will be able to explain your legal options, the potential risks and rewards of litigating a PIP claim on your behalf.

 

Personal Injury Protection - Final Wrap Up

Personal Injury Protection insurance can be complex. After an accident you do not have much time to make a claim to receive your PIP benefits. Claimants receive payouts but still may not receive their fully entitled benefit. Legal counsel is recommended.

 

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