Patient's Letter to Insurance Adjuster Regarding Use of SUBJECTIVE Pain in Diagnosis of Personal Injuries, NOT OBJECTIVE SYMPTOMS; PIP BENEFITS DENIED

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 founded upon a false diagnosis because he based it upon your SUBJECTIVE COMPLAINTS, NOT OBJECTIVE SYMPTOMS. And thus his care does not qualify as "reasonable and necessary".

She might tell you that they only have to pay for what they would expect the norm to be for soft tissue treatments in an accident such as yours. Thus, she will either deny your payments altogether, or as is more likely, she will agree to pay for those charges that normally might be expected to handle a soft tissue injury, BUT NO MORE THAN THAT (which, naturally, will be a fraction of what you have incurred in reasonable chiropractic care billings). Of course, what is left unpaid will be owed by you, to be paid out or your third party settlement.

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 in 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:

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.
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.
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.
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).
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 included within the scope of PIP because the treatments were not reasonable and necessary since the diagnosis was based upon solely subjective complaints, NOT objective findings. 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.

SettlementCentral.Com stands firm in our support of chiropractic as a healing art of choice for our members with soft tissue injuries, and we will continue to expand the topics of these rebuttal letters. We know that adjusters will employ ruses to try to avoid paying the doctor the full amount to which she is entitled. Please let us know what, if any, other issues adjusters have raised in their attacks on chiropractic care. Email us.

If you do not receive a satisfactory answer to this letter, then take a copy of the letter your doctor sent to the adjuster, and send an inquiry letter to your state Insurance Commissioner. See Letter to State Insurance Commissioner Requesting Clarification of Laws and Rules Requiring Adjuster to Value ALL Clinical Diagnoses, Whether Based Upon Objective Symptoms or SUBJECTIVE COMPLAINTS

.

This is a letter to send for initial rebuttal when the adjuster raises the objection that your pain is entirely subjective, and there is no objective evidence of any injury other than your complaints of pain. This is a tactic the adjusters will often use, and the best way to shut them down is to get an opinion letter that states almost all clinical diagnoses must be based upon subjective complaints. Please see Chiropractor Chart Note Letter to Adjuster Regarding Use of Subjective Pain in Diagnosis of Personal Injuries, not Objective Symptoms

, for more information.

Meantime, while you await one or more of the responsive letters from the insurance commissioner or your doctor, how about taking some forward action of your own to shut down the arrogant adjuster with the following letter? BE SURE NOT to mention the fact that you have written to the insurance commissioner or the doctor, just in case either of those letters does not come through just as you wished it to be.

However, you should comment that this letter is not your last word on the topic; you can state that you intend to discuss the matter with your doctor. Then you will reserve any response to the adjuster's settlement offer until you know the power of the ammunition to be furnished by the insurance commissioner and the doctor. So be sure not to make a reduction in your settlement demand in response to this tactic of the insurance adjuster; just wait and you can judge the strength of your position from the two responsive letters you are waiting to receive.

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 Insurance Adjuster Regarding Use of Subjective Pain in Diagnosis of Personal Injuries, not Objective Symptoms: PIP Benefits Denied

Your name
Your address

February 3, 2005

Name of Adjuster (be sure to get his title right; i.e. Senior Claims Representative)
His company name
The company address

Response to Charge of Subjective Complaints Coloring the Diagnosis

Dear (insert his name),

I am writing in response to your comment that my doctor's diagnosis is invalid because it is based upon my subjective complaints, and not objective evidence. I view this as a common tactic of adjusters, since we all know the value of subjective evidence in making a diagnosis is basic to our practice of medicine. Furthermore, such a diagnosis is admissible as good medical evidence at trial, and so must be considered by the adjuster in valuing the claim.

I have not as yet filed a complaint, but if I were to, I believe the insurance commissioner of our state will affirm that you are bound to act in good faith, and fair dealing, in settling PIP claims. And to raise this type of defense borders on pushing the boundaries of good faith since my doctor's testimony is clearly admissible at trial, yet you are choosing to ignore it.

Basically, I suffered significant soft tissue injuries in the accident, and my doctor diagnosed my condition based upon her examination, including my subjective complaints. She formally documented my entire treatment, from clinical diagnosis to treatment plan, including subjective complaints.

It is my understanding that subjective complaints are a valuable tool of doctors in making a clinical diagnosis. In fact, "subjective" is the first step of SOAP, the acronym for a plan for diagnosis and treatment of medical conditions (Subjective, Objective, Assessment, and Plan).

The fact is, a good clinician uses her skill and experience to assess the truthfulness of the patient, and marries her clinical observations and background into a coherent assessment to form her diagnosis. Since our medical care depends so heavily on the subjective as part of nearly all clinical work, even when there is no objective test or measurement of pain, it seems reasonable to require that adjusters should give credence to the conclusions of an experienced doctor, even if they are based upon subjective information. An example of this is the diagnosis of fibromyalgia, which does not manifest in any objective manner, but is diagnosed by subjective complaints exclusively.

It seems to me that since the insurance industry is required to exercise good faith and fair dealing in settling personal injury claims, and because an adjuster knows that a doctor's testimony regarding her diagnosis based upon subjective complaints is admissible at trial, then he is under a good faith requirement to assess the value of the claim having given due consideration to that diagnosis. Thus, if the diagnosis is good for assessing the value, it is good for requiring PIP payments

It is not fair dealing or acting in good faith to assert that such testimony is of no value in settling a claim for injury damages. As a state, we ought to insist upon those practices that demonstrate good faith and fair dealing and that encourage the settlement of insurance claims instead of litigating them. Thus, it would seem to me that if I were to bring the insurance commissioner into this debate, we could surely expect him to speak out in disagreement when presented with actions of an adjuster that are not designed to shed light on the value of a claim, but instead to act against the chances of resolving a claim by ignoring the use of information readily accepted in a court hearing.

I can also ask my doctor to comment on your position and let her explain the value of subjective evidence in making a diagnosis where there is not an objective finding. Please let me know if you would like me to obtain letters from either the insurance commissioner or my doctor in support of my observations. Otherwise, I will expect you to reevaluate your position and return with a decision to pay my chiropractic bills as incurred.

Sincerely Yours,

(insert your name)