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 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.
(insert your name)