We’re in NY. My fiance was severely injured in an auto accident a couple of years ago, and has been treating ever since. He’s had multiple surgeries and ongoing physical therapy. His auto insurer has been paying the bills out of his no-fault PIP coverage, which has a $50,000 limit. That limit has not yet been reached.
Recently, his insurer sent him to an IME (independent medical examiner) who did not perform a physical examination. That doctor claims he’s reached MMI (maximum medical improvement). Based on that determination, his insurer closed the claim. They have told him his options are to sue, to arbitrate, or to contact the NY Dept of Financial Services (insurance regulator).
His insurer has paid his medical bills and lost wages for awhile now. I guess they just got tired of all the surgeries and intermittent time off work, so they’ve closed his claim. I suppose they think we’ll go down without a fight. We won’t, but I’m trying to figure out the best way TO fight them.
I worked at an insurance company for a few years, and I understood going into the IME appointment that his insurer was preparing to fuck him over. I know we need to request his medical records from the IME. We are looking at lawyers. I am wondering if a lawyer would take a case like this on contingency, or if they’d make us pay upfront? If the case is not taken on contingency, that arbitration is likely our only option, because we can’t afford a retainer. We don’t want a massive settlement, we just want them to pay his claim up to the policy limit of $50k.
I’ve never done this before. Seeing as how he ended up with a lifelong condition as a result of this accident, I anticipate many such fights in the future. I’d like to start getting good at it now. We’re going to get a consultation with a local PI lawyer, but I don’t know what to do if we can’t afford one. If anyone has advice, I would greatly appreciate it (here in thread, or in PM if you don’t want the world to know–I’m discreet). Thanks!
50k isn’t very much money. I’m curious as to how, with 2 years of lost wages and multiple surgeries, you haven’t hit the limit already. Did you mean to type 500k?
Maybe she means he paid $50k out of pocket. One surgery would have met that threshold.
I’d start by picking up the phone and meeting with a lawyer who specializes in insurance claims. If you don’t know of any, call your local Bar Association.
$50,000 (fifty thousand) is the no-fault PIP limit. He hasn’t hit it yet, I don’t know how–this all started before I even met him. He has not been out of work continuously, just around the surgeries, and his wages weren’t high in the first place. Fortunately, his employer is pretty good at letting him return to work with restrictions.
We don’t know exactly how much of that $50k is remaining–that’s something he needs to call his insurer and ask about. If he hits the limit, he’s on Medicaid and they’ll have to take over the coverage from there. But since he hasn’t hit the limit, we need them to keep paying.
We found a good lawyer online and are going to schedule a consultation soon. Thanks for the replies, I was worrying that this was too “niche” of an issue to get any kind of answer.
Get an attorney. $50,000 seems inadequate for the damages you describe. If there is PIP coverage, there is a policy that would provide more as well. Plus, maybe you have a UIM policy or an attorney could find other places to seek compensation. Unrepresented people don’t usually get fair settlements.
We would like to. If we can find an attorney to take the case on contingency, we definitely will. “Bad faith” may be another opportunity, but that’s up to the attorney to determine.
The $50,000 limit applies to my fiance’s own no-fault PIP coverage. It is paid out to the policyholder for medical bills, *regardless of fault, *due to injuries sustained in an auto accident. Most states do not have this kind of no-fault insurance, this is a New York-specific quirk (Michigan too, and maybe a couple others). The point is that we would be suing my fiance’s **own **insurance company, not the other driver’s. I don’t think UM comes into play.
I dunno. The PD portion of the claim was settled shortly after the accident, so it’s been a few years now. I didn’t know him then, and haven’t thought to ask. NY allows fault to determine which insurer is responsible for paying for *property *damage, but that’s not at issue here and not relevant to the PIP (personal injury protection) coverage. PIP in NY is no-fault. That means my fiance’s insurer is paying his medical bills and the other driver’s insurer is paying their medical bills (if any, I dunno). All I know is that the accident was weather-related and two vehicles were involved. In those situations, the insurers’ determination of fault could go either way, or even be split 50/50.
So, although I’m honestly not sure how the PD coverage worked out, it’s not relevant here. The medical coverage is no-fault, and they’ve been paying his bills all along because of that.
**Rechellelogram **(I am not a lawyer) In my opinion your fiance has two possible claims. One with the PIP coverage and possibly one against the other driver. I have no experience with PIP claims but there must certainly be a method to appeal this decision if you feel it is not proper.
Other other claim against the other driver has two key things you need to think about.
When did this happen? Three years is the posted statute of limitations for bodily injury claims. You can verify this fact on line.
Does this meet the “PIP threshold.” In NY you can recover pain and suffering from the at fault party if your injury is a “serious injury” Again search PIP Threshold in NY for details. If it is a “serious injury” suit against the other driver may be warranted.
Get thee to a lawyer post haste. The good one don’t charge to consult.
Thank you Jimson! We’re contacting a lawyer, will post back with results. I really don’t know who was at-fault. It’s good to know that’s an option. I’ll let the lawyer decide what to lob at them, anyway.