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Posted On November 21, 2013 Personal Injury

Setting up Your Medical Claim

Now that you understand the basics of how to interact with your and the other party’s insurance companies, including what tricks to watch out for, you have all the knowledge you need to begin the claims process. It starts with opening your medical claim through your own insurance company.

What No-Fault Laws Mean for Your Medical Coverage

Both Pennsylvania and New Jersey have no-fault automobile accident laws. Of course the accident is someone’s fault – if it wasn’t, you would have no basis for a claim. What “no-fault” really means is that regardless of who is at fault, each party’s automobile insurance policy is required to pay for his or her own medical bills. No-fault laws are the reason that policies in Pennsylvania, New Jersey, and states with similar laws include Personal Injury Protection, or PIP, coverage.

The amount of coverage you have depends on the choices you made at the time you set up your policy. In New Jersey, the default PIP coverage offered by insurance companies is $250,000, but policyholders can choose to lower their PIP coverage to as little as $15,000 in order to save money on their premiums. In Pennsylvania, the minimum amount of PIP coverage required by law is just $5,000. If you choose to purchase a lower amount of PIP coverage and don’t have an applicable health insurance policy to pick up the difference, you could end up being personally responsible for any medical expenses that exceed your coverage limits. You will also have to pay the deductible you selected when you set up your insurance policy, which can range from a couple hundred dollars to a couple thousand dollars, and you will be responsible for making copayments equal to 20 percent of the cost of the medical expense.

Understanding PIP: The Basics

Your Responsibilities The Auto Insurance Company’s Responsibilities
Deductible: minimum of $250 (can be as high as $2,500, depending on your policy) None – The deductible is your responsibility to pay out-of-pocket.

Tip: If you have health insurance, you may have the option of listing them as a secondary insurer. Your health insurance policy may cover some or all of your deductible.

Copayments: You are responsible for paying 20 percent of the first $5,000 of medical bills, minus the cost of your deductible The insurance company pays 80 percent of the first $5,000 of medical bills, and the remaining medical bills in their entirety up to the coverage limit you selected.

Tip: If you have health insurance, you may have the option of listing them as a secondary insurer. Your health insurance policy may cover some or all of your copayments.

Out-of-pocket maximum: If you chose the lowest deductible amount, the lowest* out-of-pocket maximum payment you will be required to make is $1,200. None – The deductible and copayments that make up the out-of-pocket maximum are your responsibility.  If your medical bills exceed your coverage limit, you may be responsible for those bills, too.

Tip: Check your policy for coverage limit information. In New Jersey, the default amount of PIP coverage is $250,000, and the minimum is $15,000. In Pennsylvania, your coverage limit could be as low as $5,000.

* Your out-of-pocket maximum varies depending on the deductible you selected when setting up your claim. If you chose a $2,500 deductible, you could get stuck paying up to $3,000 out-of-pocket.

Tip: Auto insurance policies are complicated. If you don’t understand your coverage, it may be worth paying a lawyer a one-time fee to review your policy and explain your coverage to you.


Keep in mind that you also made a choice when setting up your policy regarding whether to make PIP or a separate health insurance policy your primary source of medical coverage in case of a car accident. If you chose PIP as primary, which our office always recommends to New Jersey and Pennsylvania drivers, you will open a claim with your auto insurance company. If you made health insurance coverage primarily responsible, you will be dealing with your health insurance company instead in this matter. In these states, you may have to pay the health insurance company back from any settlement you receive from the other driver’s insurance company, while you wouldn’t have to do so if your auto insurance company provided the coverage. We’ll talk more about money that you may owe out of your settlement in the future.

Many policyholders don’t know what their policy covers, what coverage limits they chose, or who the different types of coverage would actually impact their lives. Unfortunately, you could be in for a lot of frustration in dealing with your claim.

For the sake of simplicity, let’s assume that you selected PIP as your primary coverage. This means you will contact your own insurance company to begin getting medical treatment. You will usually begin with a simple phone call or form.

What to Expect

You will most likely set up your medical claim with your insurance company over-the-phone to save time. If you need medical care right away, you certainly don’t want to wait for a letter to reach the company via postal service and then wait for their response. Some insurance companies may allow you to submit a claim online, but you will still have to correspond with the insurance adjuster virtually, if he or she doesn’t simply call you, anyway.

The adjuster will likely ask you basic information, such as your own policy number and contact information. He or she will ask where the accident occurred and, in all likelihood, what happened. While you can give a brief explanation – such as saying, “the other car hit me from behind” – you shouldn’t have to go into great detail. After all, you don’t have to prove fault for your medical expenses to be covered. Your insurance adjuster may also ask you questions about the other vehicle and driver, so have handy all of the notes you took at the scene of the accident about the driver’s contact and insurance information. The adjuster may also ask about property damage.

The adjuster should ask you if you were hurt – but be careful, because some adjusters will phrase the question in a misleading way, such as saying, “So there weren’t any injuries, right?” Now is not the time to be shy. Let the adjuster know that you are feeling some pain and need to get medical treatment. Remember, you don’t have to talk about your injuries in detail. If it seems that the adjuster is more interested in trying to get more information out of you than in helping, remind them that you won’t know any further information about your injuries until after you see a doctor, and that you need them to help you set up your medical claim to do so. Your insurance adjuster may ask you what doctor you are going to, but you don’t have to answer or even know that answer just yet. Unlike a healthcare insurance company, your auto insurance company is not allowed to determine which doctors you may see or require you to go to a physician “in your network.” When PIP provides your medical coverage, you can see any doctor you want.

If the accident happened a few days or longer ago and you still haven’t sought treatment, be prepared for the adjuster to ask why you suddenly want to see a doctor. Any gaps in treatment, or between the date of the accident and the date of starting treatment, can make your claim seem weak. If your pain has gotten worse in the time since the accident occurred, you can tell the adjuster so. Though insurance companies are known for giving policyholders a hard time due to treatment gaps, it’s certainly true that some injuries that seemed minor when the accident happened can get worse over time.

By the end of your conversation, the insurance adjuster should assign you a claim number. It’s essential that you write down your claim number, and that you keep it handy. You will need this information when you go to the doctor, and anytime you have to communicate with your insurance company directly. It may be a good idea to keep your claim number written down in a few different important places. Keep a copy with your files and all of your documentation. Keep another copy in your wallet, purse, or other items that you will have with you during all medical appointments. You may also wish to save the information in a cell phone. The first question an employee of your insurance company will ask you is your claim number. Without it, you may not be able to get the help or answers you need. If you don’t have the claim number when you visit your doctor, especially during the initial visit, it could cause problems with billing that could leave you unfairly responsible for paying the balance.

The Passenger’s Dilemma

If you’re a passenger injured in an auto accident, the previous explanation of PIP coverage may have provided you with more questions than answers. After all, if every driver’s auto insurance policy pays for his or her medical expenses, who pays for yours?

There’s a hierarchy of coverage for passengers. If you have an auto insurance policy of your own, you would need to report the accident to your insurance company, even though you weren’t the one driving and your car may not have even been involved in the collision. You must file a claim with your insurance company just as the car’s driver would do through his or her insurance company, and your PIP coverage would pay toward your medical expenses. However, say you don’t personally own a vehicle, so you have no auto insurance coverage. In this case, you may be covered by an auto insurance policy held by a relative in your household.

As a passenger, you weren’t at fault for the accident, and you have every right to pursue a bodily injury claim for medical expenses if you’re not covered under a personal or household policy.

If no one in your household has auto insurance, then you would have to pursue bodily injury compensation through the insurance company of one of the drivers. Typically, you would seek compensation from the at-fault driver’s insurance company first, but if necessary, you could go through the insurance policy of the driver you were riding with, even if he or she was not at fault. When you pursue a claim through the insurance company, you don’t have to worry that the driver, who you probably know, will suffer any financial harm. At this stage, you’re dealing only with insurance companies. Even if you need to hire a lawyer and pursue a lawsuit, you won’t have to seek money from your friend or relative directly.

In the unfortunate event that no driver involved in the accident has insurance, you can try to access funds from a state program, like New Jersey’s NJPLIGA. As a passenger, your path to getting medical coverage may have more obstacles, especially if you don’t have an auto insurance policy yourself. You still need medical care to get better, so either pay out-of-pocket for the time being and keep documentation of every payment or consult a lawyer. The bills may be expensive, but you can’t put a price on your life or your health.

Medical Care in Non-Motor Vehicle Accidents

While setting up an official medical claim applies mainly to victims of car crashes, you should also treat an accident not related to a motor vehicle as a claim. This means keeping documentation of all medical expenses and bills related to an event such as a slip-and-fall. Make sure you get receipts for any payments you have to make out-of-pocket, including copays toward your health insurance policy if you have one. If you don’t have health insurance, you may be able to negotiate payments with your medical provider directly. Hopefully, you won’t be in a situation in which you can’t afford the medical care you need, but if so, it may be time to look for a lawyer who can represent you and request that your doctor hold off on billing you until your case is completed. However, there’s no reason you can’t submit a similar written request to your doctor on your own – the worst that can happen is that your medical provider declines to accommodate your request.

Once you’ve opened your medical claim and started getting treatment, you need to notify the other insurance companies involved – those of any at-fault parties – about the accident. Check back for the next installment of How to Handle Your Own Personal Injury Claim for help determining who to contact and how to go about it.