One of our primary areas of practice is personal injury protection benefits (PIP Benefits). When an automobile collision occurs, PIP Benefits are there to provide immediate coverage for medical treatment relating to the accident. They also provide coverage for actual lost wages and paying others to do things that the injured person would normally do around the house.
These benefits are so called - No Fault benefits. Meaning that it does not matter who was at fault in the collision the benefits apply.
A primary purpose of PIP Benefits is to “provide an inexpensive and uncomplicated procedure for obtaining compensation for injuries sustained in automobile accidents.” Dominguez v. Liberty Mut. Ins. Co., 429 Mass. 112 (1999). However, the purpose of PIP Benefits was also to "control costs of compulsory automobile insurance." Id.
Dominguez, is a definitional court decision regarding PIP Benefits; the Supreme Judicial Court found that an injured person was required to cooperate and deal in good faith with both his automobile insurer and his health insurance provider.
Generally when an individual has private health insurance, the PIP Benefits cover the first $2,000.00 of medical expenses. After that, private health insurance has to cover any medical expenses. However, if health insurance cannot cover such medical expenses, the automobile insurance will cover up to $8,000.00 in medical benefits. This includes a patient's copay's and health insurance deductibles.
In Dominguez, the patient went outside of his covered HMO. This meant that his HMO was not required to pay for his medical treatment. The Court found that likewise the automobile insurer was not required to pay for his medical treatment because they determined that the patient had an affirmative obligation to go - in network, and be covered under the health insurance he had.
The Dominguez decision creates a problem for people with limited health insurance coverage. If your health insurance only allows you to see a limited group of providers then your PIP Benefits are less valuable than someone with no insurance, because they can see anyone they want and be covered. Functionally, it makes it tougher for individuals and medical providers attempting to be paid for their work.
If you are in an accident, please call us and we can help guide you through this process. If you are a medical provider and having issues with coordinating benefits, please give us a call as well.
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