After a terrible car accident, you make progress towards recovery by attending physical therapy (PT) or occupational therapy (OT) sessions consistently. Suddenly, your auto insurance provider refused to authorize further sessions.
Under Michigan law, your personal injury protection (PIP) benefits should cover all necessary medical care to help you heal, which includes PT and OT. Understanding the steps you must take to protect your rights is crucial to your recovery.
Tactics insurance companies use to deny benefits
Long-term rehabilitation can be expensive, causing insurance companies to lose money. To protect their bottom line, they use utilization reviews (UR) and independent medical examinations (IME).
A UR refers to a process where medical professionals evaluate your doctor’s recommended treatment plan. An IME involves an evaluation where a licensed physician chosen by your insurance carrier examines your injury and disability status. Unfortunately, adjusters take advantage of these methods to find a reason to stop your payments.
Why the medical plateau myth is not what you think
Based on your UR and IME findings, an adjuster can deny your benefits because you have reached maximum medical improvement (MMI). They want you to believe that your recovery has plateaued, which means that your condition cannot significantly improve with further treatment.
MMI does not mean you can no longer heal, nor does it legally absolve your insurer of its duty under the Michigan No-Fault Act. If continued therapy is a must to maintain your current physical function or prevent your condition from worsening, it is still legally necessary.
Steps to take to stay in treatment
If your auto insurer cuts you off, here are three recommendations you may use:
- Consider backups: If your health insurance is primary, or if your auto PIP policy limits are fully exhausted, you may seek coverage through your health insurance provider.
- Secure a Letter of Medical Necessity: Request this document from your treating physician to prove why OT or PT remains essential for your recovery. When your treating physician explicitly outlines the clinical risks of halting treatment, it provides the exact medical ammunition needed to legally challenge the carrier’s denial.
- Negotiate with the clinic: Discuss with the clinic if you can establish a payment hold to continue vital therapy sessions without immediate out-of-pocket payment.
The absolute worst thing you can do right now is walk away from your therapy appointments.
Fight for your right to have a proper recovery
If you stop attending your scheduled PT or OT, you hand a massive victory to your insurance company. Defense adjusters will point to your absence and claim you must have completely recovered, creating a devastating “gap in treatment” that can ruin your legal case.
Because this matter can be overwhelming to handle alone, seeking legal guidance is advisable. A car accident attorney can offer insights on finding a way to move forward.