Failure to Timely Send PIP Denials Entitles Claimant to Presumption
From the desk of Josh Hayward: Under Oregon’s PIP statutes, an insurer must send written denials to the insured within 60 days of receiving a claim for medical expenses. Failure to do so results in a presumption that the medical expenses were reasonable and necessary. But does an insured’s refusal to attend a medical examination toll that deadline? Read on to find out.
Claims Pointer: In this case arising out of a car accident, the Oregon Court of Appeals held that an insurer must send written denials to the insured within 60 days regardless of whether the insured is cooperating with its investigation. The case is a reminder that in order to avoid a presumption that the medical expenses are reasonable and necessary, the insurer must timely send written denials, even if the insured refuses to cooperate with the investigation.
McBride v. State Farm Mut. Ins. Co., 282 Or App 675 (December 7, 2016)
Erin McBride (“McBride”) was rear-ended in November 2011. Following the accident, she submitted and was reimbursed for medical expenses through June 2012 under her PIP coverage with State Farm Mutual Insurance Company (“State Farm”). In July 2012, a State Farm claims representative called McBride to arrange a medical examination in accordance with the policy to assess the medical expenses that she submitted in June. The exam was scheduled for August 2012, but McBride failed to attend. (She later testified that she did not know why she did not show up for the exam, but she had made the decision not to attend). State Farm attempted to reschedule the exam with McBride’s attorney, but they received no response, and McBride never participated in State Farm’s requested medical exam.
Due to McBride’s failure to cooperate with the medical exam, State Farm refused to pay the medical bills pending from June 2012 and after. Notably, State Farm did not send a timely written...