February 3, 2005
The Honorable (insert Insurance Commissioner's name)
Insurance Commissioner, State of (insert name of state)
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.
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. As it now stands, I can work an entire day without suffering debilitating pain, I have been able to do my household and outdoor chores without suffering, and I have been able to sleep at night without waking because of pain.
Yes, it is true that Dr. Clark says I must continue on these treatments for some time in order to maintain the level of healing he has achieved. The adjuster counters that this is evidence that the adjustments did not "cure" me, and thus they are not covered under the policy.
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 "discounting" a large portion of my doctor's billings because she (or a so-called mystery "peer review" committee or person-she declined to say which) had concluded that Dr. Clark's charges were for treatments that were not "reasonable or necessary". This, she said, meant that the treatment costs fell outside of my company's obligation to me under its PIP provisions.
She 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 she was 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. She responded that she was 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. She 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, she said that "would not be possible".
I told her 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. She 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 her that it is not certain when or if I would be entirely "cured", and she 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 her to put her decision in writing to me.
Information and Rebuttal Furnished
Doctor Clark furnished (insert name of adjuster) full information to explain that his treatments helped to restore my health, but not completely, that her standard of "palliative, not curative" has no place in auto injury claims (although it did in worker's compensation claim), and that many other medical treatments are made and paid for on the basis that they will just let the patient live a little better or longer, while there is no chance whatsoever they will "cure" the underlying disease.
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 what treatments I can have so long as the treatment help me lead a normal life, as opposed to living in pain? If they wish to make policy changes, the insurers 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 new clauses and on top of it use a mystery source of "peer review" as authority. That is not at all what the policy says. We, the insureds, have full right of access to all reasonable and necessary medical treatments, and this is an arbitrary and capricious attempt to save insurance company money at the risk of derailing the improvements those treatments have wrought.
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.
(insert your name)