July 21, 2019
Insurance adjuster (insert her title, if known)
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.
(insert your name)