Complaint Letter to State Insurance Commissioner Regarding PIP Adjuster Discounting Chiropractor Billings Allegedly Above the "Norm for the Area"

 
Your name
Your address
 
February 3, 2005
 
The Honorable (insert Insurance Commissioner's name)
Insurance Commissioner, State of (insert name of state)
Address
 
FILING OF CONSUMER COMPLAINT: AUTOMOBILE PIP INSURANCE
Company: (insert name of company)
My policy number: (insert your policy number)
Adjuster: (insert name of adjuster)
Date of Loss: (insert date of accident)
Nature of Complaint: Failure to pay chiropractor bills under PIP provisions of policy
Last Correspondence: (insert date of your letter to adjuster); copy enclosed
Documentation enclosed: letter from Doctor M. Clark, D.C. addressed to (insert name of adjuster)
 
Dear (insert name of Insurance Commissioner)
 
I hereby file a complaint against the above-named company, and adjuster, for the reasons stated above, as more completely set forth below. I request that you investigate this matter and take appropriate action to require my insurance carrier to comply with the terms if its insurance policy.
 
History-Treatment
 
I am an insured under the above-referenced policy, and I am entitled to payment for reasonable and necessary medical care under terms of the PIP provisions of said policy.
 
I was injured in an automobile accident on (insert date). As a consequence, I undertook a course of treatment through my doctor, (insert your chiropractor's name).
 
My treatments have been frequent (4 each week, thence 3, thence 2), and they have extended many months now. I work as a (insert job), and also have the usual chores at home. Sometimes after this accident my work was difficult for me because (insert some reason here), and I did miss some work because of pain. I also had trouble doing my daily chores, and often found that I would suffer pain at night or the next day if I would extend myself doing activities during the day.
 
Dr. Clark was a lifesaver in that his treatments made my life bearable again. If it were not for the treatments from Dr. Clark, I would have missed a lot more work and would not have been able to live my life with as little pain as I do.
 
Adjuster Declines to Pay Medical Bills
 
On (insert date of adjuster's phone call or letter denying PIP benefits) (inset adjuster's name) informed me she was going to deny me benefits due under my PIP policy. Specifically, she informed me that she was going to "discount" my doctor's billings by thousands of dollars because she felt his charges exceeded "the norm for the area" on a per-treatment basis. She told me that since the bills exceeded the "reasonable and customary charges", they were, by definition, not reasonable.
 
Information and Rebuttal Furnished
 
Doctor Clark furnished (insert name of adjuster) full information to explain why his average treatment cost might be higher than others, and his billing practice is perfectly legal and within generally accepted chiropractic office practices. A copy of his letter is enclosed.
 
My rebuttal letter to the adjuster is enclosed. It was written to provide additional information and to present my point that this is a new clause added to the contract without my permission. Why should the company have the right to determine which doctor I can see? If they wish to do so, they should be made to apply at your office to change their policy, and if approved, then publicize these contract changes to their insureds.
 
But there was no such application filed in your office because the company decided to implement these changes without informing you. One would think it is obvious that they cannot just invent some figure as "the norm in the area" and expect their insureds to quit doctors they (the insureds) selected and instead go to the cheapest providers. That is not at all what the policy says. We, the insureds, have full right of choice of doctors according to the PIP policy in force at the time of this accident.
 
My choice of doctors is the one that will help me to stabilize and recover the soonest. Isn't that my right under this insurance policy? By limiting me to the lowest common denominator, the insurer is trying to force upon me ITS THEORY of what is best for my recovery. I elected to believe my doctor, who I chose with care and in whom I have placed by faith. This company has no business trying to manipulate my medical care so they can save money on treatment costs.
 
I mailed my letter to (insert name of adjuster) on (insert date of mailing), and now, twenty days later, I have not heard anything from her.
 
It is important to get this matter resolved, not just in my own case, but for others who will be victims of this tactic unless your office steps in and takes some action to make (insert name of company) comply with the law and adhere to its contracts with its insureds.
 
I would be pleased to provide any additional information you may require.
 
Sincerely Yours,
 
 
 
(insert your name)