Massachusetts Appellate Court Requires Auto Insurer to Provide Coverage for Chiropractic Treatments for Victim of Car Accident after Health Insurer Refuses Coverage

Legal News GavelOne of the most complicated aspects of a car accident case is ensuring that you will receive the treatment that you need and deserve for your injuries. While your insurance company may provide coverage, the policy provisions can be complex, and when multiple insurers are involved, disputes can arise regarding which insurer must provide reimbursement to your doctors for your treatments. If the parties are unable to reach a resolution regarding payment, you may find yourself receiving a hefty bill. As seasoned Boston car accident lawyers, we have assisted many victims with ensuring that their insurance coverage is applied fairly and appropriately to their claim and that they receive the reimbursement that they deserve.

In a recent appellate opinion, the court discussed a dispute between insurance companies regarding payment for treatments that a car accident victim received in 2010. The victim had a Massachusetts auto insurance policy and a health insurance policy from two different insurers. From the period of the accident until 2011, the victim received treatment from the plaintiff’s office, which offered chiropractic treatment. During each treatment, the plaintiff was billed for multiple treatments, including a hot and cold pack treatment. The parties did not dispute that the treatments that the plaintiff received were medically necessary.

The auto insurer paid the first $2,000 of the medical expenses that the victim suffered, and thereafter the auto insurer instructed the plaintiff to provide the medical treatment payments to the health insurance provider for payment. The health insurance provider made partial payments to the plaintiff but denied reimbursement for all of the hot and cold pack treatments. According to the health insurer’s payment policy, these were expressly excluded from coverage. The plaintiff did not object to the health insurer’s decision in this regard.

The plaintiff next provided an invoice for the unpaid expenses to the auto insurer, including the hot and cold pack treatments and a copy of the explanation of benefits form. The auto insurer paid for part of the treatments but denied the majority of them. The plaintiff filed an action against the auto insurer to recover compensation for the remaining treatments. The case was tried before a judge without a jury, and the court ruled in favor of the plaintiff, awarding the remaining $781 in payments for the hot and cold pack treatments. The judge also awarded the plaintiff $24,131.71 in attorneys’ fees and costs. The Appellate Division affirmed, and the insurer appealed.

On review, the appellate court began by stating that services not paid for by a health insurer cannot be reimbursed from PIP benefits if the insurer would have covered the medical services had the claimant sought treatment in accordance with his health insurer’s plan. In other words, the question became whether the hot and cold pack treatments were services that the health insurer’s policy covered. Reviewing the policy, the court concluded that the victim’s health insurance policy provided for care within the scope of standard chiropractic services and that it reimburses supportive treatment modalities in chiropractic care. Next, the court noted that the record lacked evidence regarding what constitutes standard chiropractic care, but the health insurer’s policy clearly excluded the hot and cold pack treatments. As a result, the court affirmed the lower court’s finding that the auto insurer was liable for the treatments.

If you were injured in a car accident, it is critical that you speak to a knowledgeable Boston personal injury attorney as soon as possible. At the Law Office of Michael O. Smith, we have handled many claims on behalf of victims, which includes negotiating with insurance companies and ensuring that you receive the treatment and coverage that you deserve. To schedule your free consultation, call us now at 617-263-0060 or contact us online.

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