The Insurance Medical Examination Cut-Off

An insurance company cannot deny payment to a treating physician, unless the insurance company first obtains a report by a physician stating that treatment was not reasonable, related, or necessary. Without such a report, the insurance company who discontinues payment is in violation of the No-Fault laws and a lawsuit is appropriate.

Even with such a report, a lawsuit is in order when the treating physician disagrees with the insurance company doctor's opinion. It is the treating physician who has seen the patient; and it is the treating physician who is best able to determine what treatment is reasonable, related or necessary for injuries their patient sustained in an automobile accident.

In some instances, insurance companies deny no-fault claims for services prior to an insurance medical examination date because the insured/patient did not appear for a scheduled exam. An insured/patient is required to attend medical examinations scheduled by his or her insurance company. If a person unreasonably refuses to submit to an examination, the no- fault carrier is no longer liable for subsequent no- fault benefits. Consequently, should the insurance company take the position that pre-exam date bills will not be paid due to the insured's failure to appear at the exam, a no-fault lawsuit is appropriate.

To succeed in a lawsuit against the insurance company for an improper insurance doctor cut-off, the medical provider should continue to submit the bills to the insurance company for consideration. If the properly submitted bill is not paid within the 30 day time period, a lawsuit is appropriate. Again, it is strongly recommended that detailed office procedure be used to document when the bill was submitted, who submitted the bill, any telephone calls or correspondence relating to the submitted bill, and documentation of non-payment after 30 days. The medical provider should supply this information to the attorney representing it or its patient.