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Letter to the Insurance Adjuster Re: Chiropractic Care being PALLIATIVE, NOT CURATIVE, and Hence Neither Reasonable nor Necessary


 
What should you do if your PIP adjuster tells you that she is not going to pay the full amount of your chiropractor's billing? It is not uncommon for adjusters to try to discount a very large bill for chiropractic care. In the past they have resorted to a couple of ruses, one of which is the topic of this letter: an allegation that your doctor's charges are neither reasonable nor necessary because they are for a service that does not "cure" the "alleged problem" (please notice that she will not call soft tissue injury-even severe deterioration of structure-a "disease" as we all do). What she is saying, in effect, is that there is no need to pay for any chiropractic care, unless it can be shown to have been of benefit in "curing" the patient.

A present-day offshoot of this is where the adjuster will allow an "expected amount" of care, based upon the trauma of the accident, but in the absence of a "cure", all other chiropractic care must be denied. Sometimes the adjuster will reinforce her arbitrary and capricious actions by attributing the decision (of how much care the "average" person would need) to the all-knowing "peer review. Any chiropractic care determined to be in excess of that will be denied.

The first thing you should do is to ask her to submit that explanation to you in writing. That will give you something to work with in rebutting her assertions-and if complaining to your state Insurance Commissioner, if necessary.

The next thing to do is to make a good record of the conversation, with all basics of time, etc., plus as much of her diatribe as you can remember.

The third thing to do is to discuss this topic with your doctor. He will not be offended to hear that someone has challenged his billings because if he is like many other good injury doctors, he has heard much of it before. You can assure him of your continued faith in his professional care, and at the same time ask him what he recommend be done.

Some doctors will just accept the discount, figuring it is not worth the fight over a few thousand dollars. If he does this, it means he will accept what your insurance company has offered and he is willing to write off the balance, leaving nothing owing by you.

While that may sound pretty good to you, it should not be an acceptable solution for five reasons:

1. The discount will work its way into your general damages award; the third party adjuster will know about it and thus not only will your total medical special damages be lower, your multiplier will be lower, and, worse, your entire course of treatment, the backbone of your claim, will be suspect-by your own doctor's admission.
 
2. Since the adjuster would not try this tactic unless there were some money on the table, you must have a very large chiropractic bill, and hence the total value of your claim might exceed the of the third party and you will be looking to your own UIM coverage; by assenting to this abuse, you will have poisoned your own UIM claim inasmuch as it is with your own company.
 
3. It is morally wrong; you paid for insurance to cover your reasonable and necessary medical expenses and it is wrong to let the company skip out on its obligation to you.
 
4. Fighting this abuse will work to your benefit in both arenas-the PIP and the third party claims; the adjuster will see you as a person who is informed, organized, and serious in pursuit of your rights; thus, the PIP adjuster is less likely to attempt requiring you to go to an IME, and the third party adjuster will be less likely to take a run at attacking your choice of treatment (i.e., medical doctor versus chiropractor).
 
5. It sets a bad precedent for those who will follow you with this same doctor or this same adjuster, who will now be emboldened by the doctor's meek acceptance.
 

Use this letter to refute the allegations of the insurance adjuster that your chiropractor's billings are not reasonable or necessary because the treatment is merely palliative, not curative. This letter is specifically addressed to one topic, but you can use the concept, including a supporting letter from your doctor, to expand to any other topic.

If you do not receive a satisfactory answer to this letter, then take a copy of it and a copy of the letter your doctor sent, and make a complaint to your state Insurance Commissioner.
 
Please remember that this is just a sample letter, and you will need to change the facts to fit your own specific circumstances.

Example Letter to the Insurance Adjuster Re: Discounting Your Chiropractor's Billings Because Treatment is Palliative, Not Curative


 

Your name
Your address

July 21, 2019

Insurance adjuster (insert her title, if known)
Insurance company
Its address


RE: My claim number:
Date of Loss:

DEMAND FOR PAYMENT OF PIP BENEFITS

Dear (insert name of adjuster)

I am writing in response to our recent phone conversation wherein you informed me that you were "discounting" a large portion of my doctor's billings because you had concluded that his charges were for treatments that were not "reasonable or necessary". This, you said, meant that the treatment costs fell outside of my company's obligation to me under its PIP provisions.

You explained that my doctor's charges are neither reasonable nor necessary because they are for a service that does not "cure" the "alleged problem". I asked if what you were saying, in effect, is that there is no need to pay for any chiropractic care, unless it can be shown to have been of benefit in "curing" the patient. You responded that you were going to pay for "a major part" of my first three months of care, but no more than that because that is sufficient care to help a person who had been in an accident such as mine. You then mentioned that some kind of "peer review" committee or doctor made these conclusions, but when I asked to be put in contact with this group or person, you said that "would not be possible".

I told you that this was all news to me and that I did not know my policy limited my care in such a manner. I also mentioned that I had been helped by Dr. Clark's good care, and as a result I have been able to work without having pains from sitting at my desk all day and also that I can do more activities in my personal life because of the treatments. You responded that I would have been able to do those things anyway if I had just taken a pain killer and let my body heal with rest.

I told you that it is not certain when, or if, I would be entirely "cured", and you responded that was the point: chiropractic could not cure me and it was just helping me to "make me feel better temporarily, that is all." I responded that I thought that was what I bought my PIP to pay, and that I wanted ALL of the charges paid as billed, AND for you to put your decision in writing to me.

Without waiting for your letter, I am writing to ask that you honor my contract with the company and pay the full amount of Doctor Clark's billings. You are not entitled to decide to quit paying just because I still have to undergo treatments. What does it mean to be "cured"?

Isn't it enough that Dr. Clark made my life so much better, that his treatments allowed me to work a full day (whereas before, I was in debilitating pain by noon), that those adjustments allowed me to do my household and outside chores without pain, and that because of Dr. Clark I have been able to sleep the whole night through?

When I bought my PIP coverage no one told me I could only have care if it "cured" me. That is a new term you are trying to add to the contract. Also, what is this so-called "peer review" committee or person? How can you use such a source without letting me know who it is?

I would like for you to send me the alleged report that they (or he?) wrote in my case. I would like to see the entire study of how they figured out how much care an "average person" would need for an accident like mine. And also, how did they measure the amount of trauma I suffered versus these supposed "average" injured patients. This does not make sense, and I think it is bogus. And since you are terminating my chiropractic care because of this mystery study, please furnish a copy to me as soon as practicable.

This is entirely foreign to my policy terms, and I would like to know what gives you the right to impose such new terms on me after I have had a claim. What you are trying to do is to add an extra clause to my contract without my permission, and I am going to resist that. I have asked Doctor Clark about this and he reviewed my chart and will write some kind of explanation to you.

Finally, I want to let you know that my intent is to cure this situation, not just for my claim, but for others who will come behind me and become victim to this tactic. Therefore, I am respectfully requesting that you reverse your position and pay Doctor Clark's billings in full. Please send me a copy of your payment transmittal letter so I can be sure this has been handled.

Should I fail to receive such a written notice of reversal of this policy within 15 days of the date of this letter, I will be forced to file a complaint with the state Insurance Commissioner.

I am still hoping to resolve this PIP claim amicably and without resort to complaints, so I look forward to working with you to complete all payments as soon as practicable.

Sincerely Yours,



(insert your name)