Mistake #7: Stopping your medical care when you have an injury because your no-fault insurance benefits have been terminated.
If you’ve had an accident or injury, if, after a few weeks you feel fine and no longer need medial care count your blessings. Be thankful for your health and thankful that you will not need a personal injury attorney. However, there are some injuries, such as simple fractures, scars and soft tissue injuries that can have a tremendous impact on your life for years to come and which are worthy of a personal injury claim. 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.
Of course, there are many medical providers who will treat you only as long as the no-fault automobile insurance continues to provide payments. Once those benefits have stopped, many doctors will stop your treatments for fear they will not be paid for their services.
Under New York State Law, all motor vehicle are required to carry and provide a minimum of $50,000 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 their claim is filed their own insurance company will send them to a doctor for an “independent medical examination.” As I have said in this publication many times before, there is absolutely nothing “independent” about the examination or the doctor’s opinion. Once again, insurance companies are not in business to pay you benefits; they are in business to make money – period.
Here is how it works: a doctor is hired by the insurance company or hired 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 that you have no physical limitations and require no further medical care (ignoring the fat that you have a dis herniation compression your spinal cord that cause substantial weakness in your left arm. If the doctor finds a
limitation, he or she will usually say it is from a preexisting condition and is 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 is it possible that this secondary assessment can adversely affect your case? It is 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 injuries” which include:
- 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;
- a medically determined injury that prevents you from performing substantially all of your usual daily activities (i.e., work or school) for at least ninety days during the 180 days after the accident.
The law in New York state 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 case; and that can take years. If the medical treatment stops, it gives the defendant and the insurance company a basis to claim that you cannot possibly have a “permanent” or “significant” disabling injury if you no longer are under medical care. If you stop your treatment, wait a period of
time and then start your treatment up again, you are required to explain why there was a “gap in treatment.” Therefore, it is necessary to maintain consistent and ongoing medical care while your case is undecided. This can be a hardship both from a financial and time constraint perspective.
There are ways to combat this dilemma. As I’ve mentioned before, some quality medical care providers who conclude you still require treatment will keep providing you with the care you need, 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 any treatment you may need. A word of caution here:
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 another 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 will have on your personal injury case.