In a decision earlier this month, the Washington Supreme Court held that state regulation prohibits insurers from denying a policyholder’s personal injury protection (PIP) coverage even if it is not necessary to achieve maximum medical improvement (MMI). Durant v. State Farm Mutual Auto Ins., No. 94771-6, 2018 WL 2727997 (Wash. June 7, 2018).
A State Farm policyholder was denied PIP coverage after a chiropractor reported to the insurer that the insured had reached maximum medical improvement. State Farm sent a letter denying coverage to the insured which stated that, “medical services must be essential in achieving maximum medical improvement for the injury sustained in the accident.” The insured argued that State Farm improperly denied his request for coverage of ongoing medical treatment after suffering an auto injury. State Farm pointed to the language in their policy, which added the MMI limitation on PIP coverage beyond statutory restrictions, to justify denial of coverage.
The Court ruled in favor of the insured, applying a strict interpretation of the statutory and regulatory scheme underlying PIP coverage. Chief Justice Barbara Madsen wrote for the court: “Excluding payment for palliative care from the reasonable and necessary medical expenses that are required to be paid under PIP coverage violates the public policy reflected in the statutory and regulatory scheme underlying PIP coverage, which is to fully compensate insureds for their actual damages from automobile accidents.”
The Court acknowledged that the code allows insurers to limited or deny PIP benefits in four circumstances: If the costs are not (1) reasonable, (2) necessary, or (3) related to the policyholder’s accident, or if the costs are not (4) incurred within three years of the accident. In this case, despite the maximum medical improvement restriction, the insured would have been statutorily eligible to receive PIP coverage for his injuries. Therefore, in keeping with public policy, the Court reasoned that the added MMI limitation was impermissible.
In Washington, limitations on PIP coverage are narrowly defined by statute leaving little room for insurers to limit coverage beyond the enumerated restrictions. The insured has the burden to prove that treatments and expenses are “reasonable” and “necessary,” but additional limitations inconsistent with the code are impermissible. Whether an insurer could include an additional restriction in a coverage policy that is consistent with the “reasonable “and “necessary” limitations on coverage is beyond the Durant decision, but could come into question in future litigation.
If you have any questions regarding PIP coverage in Texas or need defense counsel for a frivolous claim, contact the experienced insurance fraud attorneys at Parker, LLP Attorneys at Law today.