In every case prior to denying a claim for Personal Injury Protection (PIP) benefits, the insurance carrier must provide the insured with a written explanation of coverage under the policy, and include a notice that the carrier may deny, limit or terminate benefits if the carrier determines that the medical or hospital services are considered:
- Not reasonable
- Not necessary
- Not related to the accident
- Not incurred within three years of the accident.
The PIP carrier’s decision to deny, limit, or terminate the claimant’s PIP benefits must be based on the review and opinion of a medical or healthcare professional.
The term "medical or health care professional" does not include an insurance company's claim representatives, adjusters, or managers or any health care professional in the direct employ of the insurer.
The medical or healthcare professional relied on by the carrier must be currently licensed, certified, or registered to practice in the same health field or specialty as the health care professional that treated the insured.
If the claimant is being treated by more than one health care professional, the review shall be completed by a professional licensed, certified, or registered to practice in the same health field or specialty as the principal prescribing or diagnosing provider, unless otherwise agreed to by the insured and the insurer. This does not prohibit the insurer from providing additional reviews of other categories of professionals.
The insurance company’s explanation for deny PIP benefits must be so that the claimant will not need to resort to additional research to understand the reason for the action. A simple statement, for example, that the services are "not reasonable or necessary" is not sufficient.