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Personal Injury Protection Insurance (PIP)

PIP insurance is easy to purchase when you have automobile insurance. I recommend all people have PIP insurance even if they already have health insurance. PIP insurance is “no-fault”, meaning that regardless of who is at fault in a collision, PIP insurance will cover your reasonable and necessary medical bills up to the amount of your coverage. You can purchase $10,000 of PIP insurance or you can increase that to $25,000 or even $35,000, depending on your insurance carrier. PIP insurance covers health care that your personal health insurance may not, such as massage, chiropractic, and acupuncture.  All of these treatments may be helpful if you are recovering from an auto collision.

Recently, the Supreme Court of Washington handed down a pro-consumer decision regarding PIP insurance. Durant v. State Farm, 419 P.3 400, 2018 WL 2727997 (2018). In this matter, State Farm stopped paying for medical care because its insured had reached “maximum medical improvement”. As used in this context, Maximum Medical Improvement is a term meaning that a person’s medical condition is fixed and stable and they are not likely to improve. It does not mean that the person is as good as they were prior to their injury. In this case, State Farm used this basis to stop paying its insured’s PIP benefits.

State Farm’s contract said it would only pay for medical care that was reasonable, necessary, and essential to achieving maximum medical improvement for the sustained injury. However, state law says that an insurer must pay for medical services that are reasonable, necessary, and related to injuries sustained in an accident. WAC 284-30-395(1). The Supreme Court ruled that the requirement of “essential to achieving maximum medical improvement” was an additional requirement that conflicted with State law and was therefore not enforceable. It stated that Washington has a strong public policy in favor of full compensation for people injured in automobile collisions. The Court found that the only basis an insurer could deny paying PIP benefits was if they were not reasonable or necessary and that adding the additional requirement of “essential to getting to maximum improvement” was improper. The Court ruled that an insurance company may only include provisions in their policy that are inconsistent with or in conflict with the law if it is more favorable to the insured.  Durant at 405.

So, if you have PIP insurance and are denied payment for any reason other than the care was not reasonable or was not necessary, you can fight back. You can file a complaint with the Washington State Insurance Commissioner’s Office at you can contact a law firm who can assist you. The attorneys at Maxwell Graham are experienced in helping injured people fight for what they have paid for and deserve. We are here to help.