Legal Question in Insurance Law in Massachusetts

Re: Pip

The answer is, yes and no.

Yes, the defending insurance company can hire a doctor--or other medical practitioner--to review the records and bills from your treating doctor (or chiropractor, etc.) and offer an opinion as to whether the treatments were necessary and whether the bills were reasonable, but NO, this opinion does not automatically "revise" your claim downward. You are entitled to have PIP reimburse your reasonable and necessary medical expenses. If PIP pays less based on one of these reviews, you and your doctors are entitled to challenge the determination and file a lawsuit if necessary. Also, if PIP pays less than the doctor charged, the PIP insurer has to make sure that you don't get stuck paying the difference. The fight over the difference should be between PIP and the doctor.

If this "review" says your total expenses are less than $2,000, this can also affect not only your PIP claim to pay your medical bills, but also your claim against the responsible driver for "pain & suffering" damages, as the law only allows you to bring such a claim if your reasonable and necessary medical expenses are at least $2,000. Again, the insurance company's doctor's opinion does not control this issue; your own doctor's bills are considered prima facie evidence that the amount charged was both reasonable and necessary, but it will be up to a judge or jury ultimately to decide which evidence to believe and whether or not you really have more than $2,000 worth of bills.

I am concerned that you are posting this question to this bulletin board, as it implies you don't already have an attorney of your own whom you can ask these questions. If your insurance company is pulling this kind of stuff on you, it is definitley time to hire a lawyer.

Feel free to call for a free consult.

And good luck.