What Happens When Your PIP Benefits Run Out After a Massachusetts Car Accident?

If you are injured in a Massachusetts car accident, Personal Injury Protection, commonly called PIP, can help pay medical expenses and lost wages. But PIP is limited, and in some cases those benefits can run out while you still need treatment.

So what happens next?

TL;DR

• Massachusetts PIP provides up to $8,000 in benefits per person, subject to coordination with health insurance and other applicable rules.

• If PIP is exhausted, health insurance may become responsible for continuing medical treatment.

• Medicare and certain other government benefits have special coordination rules.

• A self-funded employer health plan may also have different rules.

• If you have no health insurance, continuing treatment can become more difficult, but there may still be options.

Your Health Insurance May Pay Next

For many people, the answer is their regular health insurance.

Massachusetts has specific rules for coordinating PIP and health insurance. When applicable private health insurance exists, PIP generally pays the first $2,000 in medical expenses. After that, the health plan generally becomes primary for covered medical expenses, while PIP can remain available for certain expenses the health plan does not cover, up to the PIP limit.

This means PIP does not necessarily have to pay the entire $8,000 before your regular health insurance becomes involved.

Different rules can apply to Medicare and other government health programs. Medicare, for example, is generally secondary to automobile no-fault insurance for accident-related treatment. These cases have to be coordinated carefully.

What About Employer Health Insurance?

Another issue we sometimes encounter is a self-funded employer health plan.

Most people who receive health insurance through work simply have group health insurance purchased through an insurance company. A truly self-funded plan is different. The employer itself is ultimately responsible for the medical claims, while an insurance company or third-party administrator may simply administer the plan.

Because these plans can be governed by federal ERISA law rather than Massachusetts insurance law, the normal coordination rules may not apply in the same way. We have also seen situations where a plan is described as self-funded when further investigation is needed to determine whether that is actually the case for PIP coordination purposes.

Copays and Deductibles Can Become a Problem

Even when health insurance continues paying for treatment, the injured person may suddenly face copays and deductibles.

Consider someone attending physical therapy three times a week with a $60 copay. That is $180 every week just to continue treatment.

When there is a viable personal injury claim, sometimes a medical provider may be willing to wait for certain amounts until the case is resolved. Whether a provider will agree to that depends on the provider and the circumstances of the case.

What If You Have No Health Insurance?

This is where things become much more difficult.

Some uninsured people may qualify for MassHealth. We have had clients who were seriously injured and helped with MassHealth enrollment while they were still at the hospital.

But not everyone qualifies. If PIP has been exhausted and there is no health insurance or other available coverage, we may have to look for medical providers willing to continue treatment and wait to be paid from a future settlement.

Some providers will work with accident victims this way. Others will not.

That is why running out of PIP does not necessarily mean your medical treatment has to stop, but it can make coordinating and paying for treatment considerably more complicated.

At the Law Office of Louis S. Haskell, we have extensive experience dealing with PIP, health insurance, medical providers, and the practical problems that arise when accident victims still need treatment after their PIP benefits are exhausted.

If you have been injured in a car, truck, bus, or other motor vehicle accident and have questions about your medical bills or PIP benefits, call the Law Office of Louis S. Haskell at 978-459-8359.