Written by attorney Richard Edward Noll

Should I Stop Medical Treatment Once my Insurance Benefits are Denied

If you feel fine and no longer need medical care after a few weeks – count your blessings. Be thankful for your health, but again, you really will not need a personal injury attorney. There are some injuries that are not permanent yet significant enough to pursue a claim for such as simple fractures and scars. However, a great many injuries that are “soft tissue" in nature can still be significant and have a tremendous effect on your life for years to come. While excessive and unnecessary medical care is detrimental to your claim, the lack of consistent and ongoing medical care – especially in car accident litigation- will be the death knell of your claim.

There are many medical providers who will treat you only as long as they are receiving payment from the no-fault /PIP automobile insurance provided for the accident. Once those benefits are stopped, many doctors will stop your treatments for fear they will not be paid for their services.

Under New York State Law, all motor vehicles are required to carry and provide a minimum of $50,000.00 in personal injury protection or no-fault benefits to pay for medical expenses and loss of earnings. That is not to say that an insurance company actually will pay $50,000 toward your “first party benefits". I tell my clients that almost without fail, within two to three months after the claim is filed their own insurance company will send them to a doctor for an “independent medical examination". Trust me when I tell you there is nothing “independent" about the examination or the doctor’s opinion. Insurance companies do not exist to pay you benefits. They are businesses that seek to make a profit and in turn earn money for their shareholders.

A doctor is hired by the insurance company or on behalf of the insurance company to review your medical records (which they may or may not do) and to examine you to determine whether or not you require more medical care (and thus keep costing the insurance company more money). These doctors usually perform five to ten “examinations" per day and are paid handsomely for each one. Almost without fail, the doctor generates a report stating you have no physical limitations and require no further medical care (Ignoring the fact that you have a disc herniation compressing your spinal cord resulting in substantial weakness in your left arm). If the doctor finds a limitation he or she will usually say it is from a pre-existing condition and not related to the subject accident and therefore the insurance company no longer needs to provide benefits. Under these circumstances the insurance company is permitted to “cut-off" your no-fault benefits – and there goes the ability to pay for more medical care.

How can this possibly adversely effect your case? It’s not your fault! You would have received more medical care if the insurance company doctor did not cut off your benefits. The dilemma is this – in automobile accident cases you need to prove a “serious injury" before you are entitled to payment for your pain and suffering. There is a list of qualified categories of “serious injury" including: death, dismemberment, broken bones, disfiguring scarring or deformity, loss of a fetus, permanent loss of use of a body part; significant limitation of a body part or function; permanent consequential limitation of use of a body part, organ or function or having a medically determined injury that prevents you from performing substantially all of your usual daily activities (ie – work or school) for at least ninety days during the 180 days after the accident.

The law in New York has developed in such a way that it is almost a requirement for all “soft tissue" cases that the injured person continue medical care until the end of his or her case – that can be years. Once the medical treatment stops, it gives the defendant and the insurance company a basis to claim you cannot possibly have a “permanent" or “significant" disabling injury if you are no longer under medical care. If you stop your treatment, wait a period time then start treatment again – you are required to explain why there was a “gap in treatment". Therefore it has become necessary to keep some type of consistent medical care ongoing during the pendency of your case. This can become a hardship both financially and from a time constraints perspective.

There are ways to combat this dilemma. As mentioned above, some quality medical providers who conclude you still require treatment will keep providing you with care and submit the insurance company denial to arbitration or litigation setting forth their medical reasons for the continued care and attacking the lack of sound medical foundation for the denial of benefits. If you are lucky enough to have your own medical insurance, once no-fault benefits are denied, you can use that private insurance to pay for your care. One must be careful since some private health insurance policies require you to reimburse them out of your settlement proceeds at the end of your case for the benefits they provided (this is a topic for an entire article). If private health insurance is not an option, many medical providers will work with you and your attorney to provide continued medical care at a reduced cost and frequency that will satisfy your medical as well as legal needs. You must do whatever is best for your own health and well being while being cognizant of the effects your decisions have on your personal injury case.

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