No-fault Insurance inquiry

[cmr33]

What is the name of your state? New York

I work within a physical therapy firm in Manhattan. We have been treating a patient for 12+ years as a result of an automobile accident. Her insurance company has denied payment after the tenth year of treatment though her therapy has continued. She has run a tremendous bill that we need to obtain in order to balance our finances. Who is responsible for payment, our client or the insurance company? P.S. : we have a letter from an outside physician stating that the treatment should persist. Do we need to contact a lawyer?

 

[cbg]

The bottom line is that she is responsible for her medical bills. She is free to fight it out with her insurance carrier but you are free to bill her for it and take whatever means you need to take to collect.

I can think of a couple of reasons just off the top of my head why her insurance might be no longer liable. Since neither you nor I can know for certain which, if any, of them, are the case, it would be pointless to try to determine the merits of her insurance carrier's position. However, that's her problem, not yours.

As far as her doctor saying that the treatment should continue, that's all well and good, but just because she needs the treatment does not mean her insurance has to continue to cover it if, for some reason, it is no longer a viable claim. If, for example, she has met a lifetime maximum on the insurance or if the coverage has changed and the type of therapy you offer is no longer covered by her plan, then they would not be responsible regardless of how much the doctor wants her to have the treatment.

I'm not 100% sure of this (maybe one of the lawyers can chime in here) but I believe that you can refuse to treat her until the bill is paid up. I know you can hire a lawyer or a collection agency if you are not getting paid.

But the bottom line is that it is HER responsibility to see that the bills are paid, whether she pays them or her insurance, and it is HER responsibility, not yours, to determine whether her insurance is correct to stop paying, or not.

 

[BennyDi]

There is a maximum amount of benefit on No Fault (or Personal Injury Protection) insurance in New York State. The maximum amount of coverage would be listed on the policy she had at the time of the injury. If the patient doesn't have a copy of that policy, the patient can call the insurance company she had (at the time of injury) and inquire as to the amount of coverage she had at the time of the injury. The patient can also call the claims department of the insurance company to inquire as to the maximum amount of coverage at the time of the injury, how much has been paid to date, when it was paid, to whom it was paid, and why they are no longer paying it.