The Department of Banking and Insurance (“DOBI”) has recently enacted numerous regulation changes that will adversely impact the ability of people who were permanently injured in an auto accident from fully utilizing their medical benefits under their Personal Injury Protection (“PIP”) auto coverage. These regulation changes will have a significant negative impact on an injured person’s ability to obtain medically necessary diagnostic testing and long-term treatment.
One of the regulations that will have negative widespread impact on permanently injured persons is N.J.A.C.  11:3-4.4(d). That regulation permits the insurance company to file policy language at the time of the loss advising their insured that their deductible and co-payment obligations will be waived should she/he elect to obtain treatment from a medical provider who is part of an Organized Delivery System (“ODS”) that has contracted with the insurer or its PIP vendor.
Since medical providers who are part of an ODS are approved and paid by insurers, these providers will be compelled to follow the insurers’ cost-cutting directives and treatment protocols. Therefore, it will be no surprise when these medical providers will minimize objective medical examination findings and terminate treatment prematurely despite indications that the injured person may have suffered permanent injury(s) that require further diagnostic testing and long-term care.
As a result, not only will these regulation changes curtail a permanently injured person’s ability to obtain testing and treatment to cure or relieve their injuries, the injured person’s ability to recover compensation from those persons liable for their pain and suffering will also be abridged. Due to their inability to obtain medically necessary testing and/or treatment, these injured persons will be unable to prove their permanent injuries in their court cases through objective medical evidence in the form of positive diagnostic test results and long-term care.
Thus, in exchange for not having to pay their relatively minimal deductible and co-payment obligations, by opting to use the insurers’ ODS network injured persons are giving up their ability to obtain medical treatment, as well as their ability to prove their permanent injuries during litigation. Before being lulled by insurance companies to give up benefits, it may be wise to first consult with an attorney.