Oregon Case Law Update: Oregon Court of Appeals Provides Guidance on a PIP Insurer’s Duty to Promptly Pay PIP Benefits after Receiving Proof of Loss
From the desk of Cliff J. Wilson: Under Oregon’s no-fault personal injury protection (“PIP”) statute, insurers must provide certain benefits (e.g. medical expenses and wage loss) to insured drivers involved in car accidents, without regard to fault. In the case of PIP medical benefits, the statute requires that benefits must be paid “promptly” after receiving proof of loss. The statute also provides that PIP medical expenses are deemed “reasonable and necessary” unless the PIP insurer provides the medical provider notice of denial within 60 days. Does the statute require that the PIP insurer pay the expenses within 61 days, though? Further, is the insured excused from complying with the terms of the insurance policy if the insurer does not pay the PIP medical expenses within 61 days? Read on to find out.
Claims Pointer: In this case, the Oregon Court of Appeals held that an insured party’s attendance at an examination under oath (“EUO”) was a condition precedent to filing an action for breach of contract. The court also held that the insurer’s failure to pay or deny benefits within 60 days of receiving a proof of loss was not a material breach of the insurance policy. Importantly, the court relied on this holding to reject Plaintiff’s argument that an insurer’s failure to pay or deny benefits within 60 days made such benefits immediately payable 61 days after receiving the proof of loss.
Moore v. Allstate Ins. Co., 293 Or App 690 (September 6, 2018)
Under Oregon’s PIP statute, a driver involved in a motor vehicle accident is entitled to receive up to $15,000 from their own insurance provider for “[a]ll reasonable and necessary expenses…incurred within one year¹ after the date of the person’s injury…” The insurer is required to provide such benefits “promptly after proof of...