Personal Injury Protection (“PIP”) is a type of insurance coverage that is provided along with all car insurance policies sold in New Jersey. PIP covers any medical treatment costs related to injuries sustained in an automobile accident. PIP coverage will help pay for the cost of medical treatment as well as reimbursement for other expenses such as lost wages regardless of whether you were at fault for the accident.
Under New Jersey law, an insured party can elect to receive a basic auto insurance policy that typically includes PIP coverage of up to a maximum of $15,000 per accident/person. The full PIP coverage, which we always recommend for clients, is $250,000. The $15,000 minimum is just the floor coverage that is provided within the car insurance policy and the policyholder is free to select higher coverage at their own expense for coverage up to $250,000. However, this policy limit can be statutorily increased or expanded for certain types of injuries or when medically necessary treatment is rendered to the injured person.
There also exists in New Jersey a dollar-a-day policy but you have to qualify for Federal Medicaid to even qualify. The dollar-a-day policies are also called the standard auto insurance policy (SAIP). These policies are called dollar a day because they cost $365 per year. The policies have no liability coverage and quite frankly are the worst policies I have ever seen. The legislature should do away with them altogether. Under the SAIP policies there is not even the $15,000 minimum PIP coverage. That being said, under the SAIP policies you can obtain expanded PIP coverage as set forth below.
How New Jersey Law Can Help Expand Your PIP Coverage Beyond Your Policy
Under New Jersey law, a policyholder can expand their PIP coverage under a statutory defined set of criteria. N.J.S.A. 39:6A-3.1(a), the statute governing policy limits and expansion in New Jersey, provides as follows:
Personal injury protection coverage, for the payment of benefits without regard to negligence, liability or fault of any kind, to the named insured and members of his family residing in his household, who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile, and to other persons sustaining bodily injury while occupying, entering into, alighting from or using the automobile of the named insured, with the permission of the named insured. “Personal injury protection coverage” issued pursuant to this section means and includes payment of medical expense benefits, as provided in the policy and approved by the commissioner, for the reasonable and necessary treatment of bodily injury in an amount not to exceed $15,000 per person per accident; except that, medical expense benefits shall be paid in an amount not to exceed $250,000:
(1) for all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or;
(2) for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requires critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician.
As provided above, PIP coverage can be expanded up to $250,000 for medically necessary treatment of permanent or significant brain injuries, spinal cord injuries or disfigurement, and for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident. This provision will give the policyholder peace of mind that in the event of a catastrophic accident, they will not need to worry about how they are going to finance their treatment to recover.
How to Determine Whether the Treatment Triggers the PIP Expansion
If a patient has selected automobile PIP insurance limits less than the maximum $250,000, certain treatment protocols may trigger expansion of the policy up to $250,000. There are three classes of injuries or treatment which trigger the expansion of the $250,000 maximum limits for personal injury protection benefits:
- Permanent or significant brain, spinal cord injury or disfigurement; or
- Treatment of other permanent injury; or
- Treatment at a trauma center or acute care hospital of significant injuries following an accident immediately following the accident and until the patient can be safely discharged or transferred to another facility in the judgment of the attending physician.
The third class of injury can be further broken down as to require four distinct conditions to occur prior to PIP expansion. First, there must be treatment at a trauma center or acute care hospital. Second, the treatment that is rendered must be fore significant injuries. Third, the treatment rendered must be provided immediately following the accident that caused the significant injuries. Lastly, the expanded PIP benefits will only be provided until the patient is safely discharged or transferred to another facility.
If any of the three classes of injuries or treatment are rendered or sustained, an insurance company’s attempt to impose a patient’s lower policy limits such as $15,000.00 is contrary to the clear statutory mandate of N.J.S.A. 39:6A-4.3(e).
Under many New Jersey PIP policies, any potential claims are subject to mandatory arbitration. However, these proceedings are documented and searchable in an effort to provide transparency and help individuals in determining whether their injuries or treatment fall under any of the three enumerated criteria to expand their PIP coverage.
For example, in the Matter of the Arbitration between Jersey Shore University Medical Center a/s/o H.P. v. State Farm Indemnity Company, Forthright File No. NJ2104001940283 (July 25, 2022), the arbitrator found that the injured party was in fact entitled to PIP expansion. The injuries were the result of a motor vehicle accident resulting in a moderate left ankle sprain, cardiac contusion, forehead hematoma, right eye contusion and orbital fracture along with other injuries. The arbitrator determined that the cardiac contusion met the definition of a significant injury under N.J.S.A. 39:6A-3.1(a)(2) despite the injury being healed by the time the injured party was discharged from care.
Another example comes from the arbitration proceeding in the Matter of Arbitration between Jersey Shore aso D.W. v. Esurance Insurance Company, Forthright File No. NJ 2106001951956 (May 5, 2022). Here, the arbitrator determined that injuries following a motor vehicle accident which resulted in right 4-7 rib fractures, a left fibular fracture, and a left hip fracture were significant enough to justify PIP expansion under N.J.S.A. 39:6A-3.1(a)(2).
Lastly, in the Matter of Arbitration between North Jersey Spine Group a/s/o C.R. v. Progressive Insurance Company, Forthright File No. NJ2112001976566 (April 11, 2022), the arbitrator determined that PIP expansion was required under N.J.S.A. 39:6A-3.1(a)(1). Here, the arbitrator found that the injured party’s accident resulted in a disc herniation at C5-C6 with accompanied cord compression and severe right sided stenosis. Under N.J.S.A. 39:6A-3.1(a)(1), these injuries constituted a significant spinal cord injury, and the injured party was thus entitled to PIP expansion. The arbitrator went on to state that the post-discharge treatment and surgeries were also covered under PIP expansion as N.J.S.A. 39:6A-3.1(a)(1) does not limit the benefits up until discharge as N.J.S.A. 39:6A-3.1(a)(2) does.
Scura, Wigfield, Heyer, Stevens & Cammarota’s New Jersey Attorneys provide experienced legal representation with New Jersey PIP claims. The issues discussed above require knowledge of the way to maximize recovery and best protect you and your family’s income and medical benefits. Please call our firm for a free legal consultation concerning your claim.
