This blog provides a summary of the latest New Jersey court decisions affecting PIP insurance, as well as periodic updates concerning pending legislation and changes to regulations. If you are looking for a New Jersey PIP lawyer, please contact the firm at (862)210-8424 or by e-mail at email@example.com
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The New Jersey Supreme Court has held that an insurance company is not entitled to discovery of information regarding the ownership structure, billing practices, or referral methods of the medical providers in conjunction with a PIP arbitration. Selective had, as it has done in many other matters, sought discovery from various medical providers who treated Selective's insured and then sought payment from Selective under an assignment of benefits from the patient. Discovery was sought regarding the ownership structure, billing practices and referral methods of the providers under the provision of the insured's policy that requires that an insured cooperate with Selective's investigation of the claim. Although the medical providers did stand in the patient's shoes as a result of the assignment, the Supreme Court held that the insured would have had no duty to provide discovery regarding ownership structure, billing practices and referral methods, neither did the providers who obtained the assignments of benefits. Selective Insurance Company of America v. Hudson East Pain Management
Today DOBI issued a bulletin recognizing that some insurers are not following the law regarding making $250,000 the default PIP policy limit, and issued a warning that the $250,000 limit should be the default with the consumer having the ability to select another option if they so choose. As set forth in the bulletin, insurers have been pre-populating fields online with PIP limits that are less than $250,000, and this is not permissible.
In a recent Appellate Division case, both sides to a PIP arbitration agreed that the DRP assigned by Forthright had decided the case on an incomplete record, and failed to consider documents that had been electronically submitted to Forthright prior to the hearing. Both sides agreed that the proper remedy was for the Law Division judge to remand the case to the arbitrator for reconsideration, including consideration of the documents that were incorrectly not accepted. Forthright intervened in the matter and took the case to the Appellate Division, arguing that the Law Division lacked the authority to remand the case and could only, "vacate, modify or correct" the award. The Appellate Division disagreed with Forthright and held that its position was "utterly without merit." Dr. Amrish Patel a/s/o K.F., et. al. v. Liberty Mutual Insurance Company.
In order to protect themselves from losing PIP arbitrations based upon insufficient assignments of benefits, some medical providers have been having their patients sign assignments of benefits providing that the injured person authorizes the provider to appoint a lawyer and file a PIP arbitration petition in the injured person’s own name
if the assignment is found invalid or is not accepted by the insurer. The PIP arbitration attorney would then file an arbitration in both the name of the provider and the patient individually, dismissing one party or the other depending upon whether or not the assignment of benefits was held to be valid. Although the Committee did not find this practice to be unethical, it did caution that an arbitration brought in the patient's name could possibly affect the outcome of the patient's personal injury case, and therefore the committee noted that there should be direct communication between the PIP attorney and the patient regarding the ramifications of including the patient individually as a party to the arbitration. The full text of the opinion can be found here:
The time for comments to be submitted with regard to the new PIP regulations and fee schedules proposed by the New Jersey Department of Banking and Insurance is set to expire April 21, 2012. The proposed amendments to the regulations and fee schedules can be found at
. If you wish to submit comments regarding the proposals, they should be forwarded to Robert J. Melillo, Chief, Legislation and Regulation, New Jersey Department of Banking and Insurance, 20 West State Street, P.O. Box 325, Trenton, New Jersey 08625-0325.
Effective 1/1/12, there are new EMG codes that should be used when performing both EMG and nerve conduction tests on a patient on the same day. The new codes are 95885 and 95886 and should be reported in conjunction with the existing NCS codes 95900-95904. More information can be found here:
If only EMG is performed (no NCS services are delivered at the visit) use the existing EMG codes of 95860-95864 and 95867-95870.
In an unpublished trial court decision, a Union County Superior Court judge has found that a personal injury plaintiff is permitted to introduce evidence at trial that its medical expenses exceeded its PIP policy limits, which were $15,000. In doing so, the judge took a position opposite to that of a Bergen County Superior Court judge in the unpublished trial court decision of Kim v. Kim, BER-L-5471-08 (Law. Div. May 4, 2010)
. The Court did not agree with the Insurance Company's argument with regard to the statutory interpretation of the 1998 amendments to the no-fault law contained in the Automobile Insurance Cost Reduction Act, and found that the statutory language supported allowing such evidence to be presented. Likewise, the Court opined that it was not the legislature's intention to prohibit a plaintiff from being reimbursed for thousands of dollars of medical bills because the plaintiff chose a policy with a lower premium. Cecilia Wise v. Cynthia Marienski, et. al.
In a New Jersey Supreme Court opinion issued earlier today, Physician Assistants were found to not be authorized to perform the electrodiagnostic test known as needle
electromyography (EMG). The court disagreed with the argument that a PA could perform a needle EMG based on the statutory authorization for a PA to "assist" a physician, noting that PAs do not receive a plenary license to practice medicine, the statute generally authorizing performance of EMGs refers only to healthcare professionals other than PAs, and the Board of Medical Examiners has never adopted regulations or acted with sufficient clarity to overcome the statutory limitations on the procedures that a PA is authorized to perform. Finally, the Supreme Court declined to consider whether or not its decision would be effective retroactively or only be given prospective effect, creating an unsettled situation for any pending claims were a needle EMG was performed by a PA. Selective Ins. Co. of America v. Arthur C. Rothman, M.D.
Prior to 2010, Horizon Blue Cross Blue Shield of New Jersey ("BCBS") was not required to honor assignments of benefits that were given to out-of-network medical providers. See Somerset Orthopedic Associates, P.A. v. Horizon Blue Cross and Blue Shield of New Jersey
, 345 N.J. Super. 410, 420-23 (App. Div. 2001). However, in 2010 the legislature enacted a bill that required medical carriers to honor assignments of benefits to providers, and required that a medical insurer pay the provider directly. See N.J.S.A.
26:2S:6.1(c). The New Jersey Dental Association was seeking to have the new statute applied to stand-alone dental plans as well, but the Court refused to do so based upon a specific statute that pertains only to dental plans. Although the Court found the New Jersey Dental Association's argument to be "plausible", but found that they were without authority to expand the coverage of the new anti-assignment statute given that there was a specific statute pertaining to stand-alone dental plans which addressed the issue. Consequently, BCBS is still permitted to disregard assignments from out-of-network dental providers until the legislature takes action with regard to those specific types of insurers. New Jersey Dental Association v. Horizon Blue Cross Blue Shield of New Jersey