Letter to the Insurance Adjuster Re: Denial of Benefits by Discounting Chiropractor Billings That "Exceed Reasonable and Customary" Charges

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Letter to the Insurance Adjuster Re: Denial of Benefits by Discounting Chiropractor Billings That "Exceed Reasonable and Customary" Charges

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 above the norm in the area, and thus do not qualify as "reasonable". She might tell you that they only have to pay the norm for that area, and thus she is discounting your doctor's bills. Of course, what is left unpaid will be owed by you, to be paid out or your third party settlement.

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 because the average treatment cost is above the norm.

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

September 7, 2010

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 per treatment exceeded the "norm for my area". This, you said, meant that the treatment costs were not "reasonable", and hence fell outside of my company's obligation to me under its PIP provisions.

I told you that this was the same as denying some of the treatments, that it was not right, that I did not know how Doctor Clark's charges compared with others and I did not think it was a significant difference, 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 pick and choose whom I will see for my care. I did not agree to be bound to see the cheapest doctors around. But if you make me pay the difference in these bills, you are effectively requiring me to see a doctor that I would not care to treat with.

It seems to me that you are adding another term to the policy without my permission. I do not remember when I bought this policy anyone telling me that I could not have my choice in medical care. The only standard was that the care had to be reasonable and necessary. Since you never questioned whether the treatments are necessary, I take that as a given. The only question is whether or not I should be required to doctor-shop before I commence treatment to make sure I selected someone who is in the lower half of treatment charges.

So 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. Apparently on many treatments he hits three areas defined in medical codes and so he appropriately bills for those three areas.

Your "norm" doctors must bill for the standard two code areas per treatment. That is how he explained the increase in costs.

My question to you is, who determined the so-called norm? When was the study done and how did they account for many instances where they could not tell whether billing was done via the charge-per-code method, or whether one flat per-visit charge was assessed?

I would like to see the entire study, and since you are terminating my services because of this mystery study, please furnish a copy to me as soon as practicable.

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)