Law Blog

Personal Injury Protection (PIP) and “Maximum Medical Improvement”

Many Washington drivers have PIP as part of their car insurance coverage.  Generally, PIP pays for medical treatment and lost wages, regardless of whether or not you’re at fault.  Washington law regulates when insurance providers can terminate PIP benefits.  According to WAC 284-30-395(1), an insurer can only deny claims if they are not (1) reasonable, (2) necessary, (3) related, or (4) not incurred within three years of the collision.

Now this may surprise you, but insurance companies often don’t like to pay claims because they make less money (did you catch the sarcasm?).  What some insurance companies were doing was denying based on Maximum Medical Improvement (MMI).  Essentially they would hire a doctor or other medical provider to review your medical records or do a quick examination, then that person would say you had reached MMI and didn’t need any more treatment.  This would happen despite the injured person (and often their medical providers) claiming that they were still injured and needed further treatment!

The Washington Supreme Court addressed the issue in Durant v. State Farm Mut. Aut. Ins. Co. 191 Wash.2d 1, 419 P.3d 400 (2018). The Court ruled that insurance companies, State Farm in this case, violate Washington law when they terminate benefits for any reason than the 4 listed in the WAC above.  Furthermore, the Washington Office of the Insurance Commissioner emphasized in its brief to the Court that reasonable, necessary, and related care includes palliative care.  This means that if you’re injured, and need something like massages to manage your pain, then your insurance company should pay for it.

If you believe you have been unfairly or illegally denied benefits by your insurance company, call Ember Law today.