Personal Injury Protection (PIP)

Insurance Penalty For Late Payment Of Claim

March 28, 2022 | Mark S. Humphreys

The Texas Insurance Code provides for penalties to insurance companies who pay a claim late. This is illustrated in a 2022, opinion from Texarkana Court of Appeals. The opinion is styled, State Farm Mutual Automobile Ins. Co. & State Farm County Mutual Ins. Co. Of Texas v. Greg Rumbaugh.

Greg Raumbaugh sued State Farm after State Farm failed to pay personal injury protection (PIP) benefits “not later than the 30th day after the date the insurer received satisfactory proof of a claim,” as required by Texas Insurance Code, Section 1952.156. Cross motion for summary judgement were filed and the trial court ruled in favor of Rumbaugh. This appeal followed. The sole question raised in this appeal is whether the trial court erred by resolving cross–motions for summary judgment in Rumbaugh’s favor, thereby determining that he was entitled to statutory penalties under Section 1952.157 of the Texas Insurance Code even though PIP benefits were paid before the lawsuit was filed.

PIP coverage is a form of no–fault insurance. PIP’s limitation to medical expenses and lost wages, along with its collateral-source and no-fault features, are designed to simplify and hasten claim resolution and payment. Because Section 1952.157 provides for “a penalty of 12 percent,” among other things, if an insurer fails to pay PIP benefits “when due,” the trial court properly ruled that Rumbaugh was entitled to statutory penalties when PIP benefits were paid past Section 1952.156’s statutory deadline, even though they were paid before the lawsuit was filed.

Personal Injury Protection (PIP) Benefits

May 10, 2020 | Mark S. Humphreys

Personal Injury Protection (PIP) is a coverage which is required by Texas law to be offered when a person purchases automobile coverage. One of the questions regarding this coverage is, why is it paid. This issue was partially addressed in the 2020, Texas Supreme Court opinion styled, Farmers Texas County Mutual Insurance Company v. Rodney Beasley.

In this case the Court had to decide whether a plaintiff had standing to file a lawsuit against his PIP insurer after the insurer paid the incurred medical expenses pursuant to the PIP policy, but the amount paid was the negotiated rate between the plaintiff’s health care provider and the insurer — not the medical providers’ list rate. This Court concluded that plaintiff could not show harm and thus, the case should be dismissed.

Here, Beasley was injured in a car accident. Beasley sought medical treatment and incurred expenses with a list rate of $2,662.54. Beasley’s health insurer, Blue Cross Blue Shield (BCBS) has a negotiated rate with the medical providers and paid $1,068.90, and no attempt was made against Beasley by the medical providers to recover any further monies.

Personal Injury Protection Benefits And Offset

January 18, 2020 | Mark S. Humphreys

Most of the time, Personal Injury Protection (PIP) benefits are paid when a proper claim for them is made and then if a claim for Uninsured Motorist (UIM) benefits is made, the insurance company takes/gets an offset for the PIP benefits in any settlement that occurs. But what if the case is tried to a jury?

A case involving PIP and UIM benefits was tried to a jury in Jasper County and a Judgement was entered in favor of the insured. No offset was given for the PIP benefits that had been paid by the insurance company. How did this happen?

An appeal was taken to the Beaumont Court of Appeals and the case is styled, Allstate Fire And Casualty Insurance Company v. Andy Alfred.

Personal Protection Benefits – Occupying A Vehicle

September 8, 2019 | Mark S. Humphreys

When it comes to claims dealing with automobile policies, here is a case that needs to be read. It is a 2019, opinion from the Texarkana Court of Appeals and is styled, Alan Kiely v. Texas Farm Bureau Casualty Insurance Company.

Kiely sued Farm Bureau in an effort to recover Personal Injury Protection (PIP) benefits that had been denied. Summary Judgement was granted in favor of Farm Bureau and this is Kiely’s appeal from that ruling. This Court sustained the ruling in favor of Farm Bureau.

The PIP policy at issue provided coverage up to $10,000 per person for each accident. Texas Insurance Code, Section 1952.151, states PIP requires payment of all reasonable expenses that: (1) arise from an accident; ….

Personal Injury Protection (PIP) Offset

May 8, 2018 | Mark S. Humphreys

In Texas automobile policies where the insured has opted to purchase uninsured motorist (UM) coverage, there is an offset for amounts paid under the PIP coverage.

The basis for the PIP offset can be found in the policy language of the uninsred/underinsured motorist policy provision, which provides:

In order to avoid insurance benefits payments in excess of actual damages sustained, subject only to the limits set out in the Declarations and other applicable provisions of this coverage, we will pay all covered damages not paid or payable under any workers compensation law, disability benefits law, any similar law, auto medical expense coverage or Personal Injury Protection Coverage.

What Does PIP Cover And Not Cover?

April 24, 2018 | Mark S. Humphreys

Insurance lawyers in the Dallas and Fort Worth area need an understanding as to what Personal Injury Protection (PIP) benefits cover and do not cover.

PIP consists of reasonable expenses incurred for necessary medical and funeral services as well as replacement of 80% of income lost during the period of disability up to the amount of PIP policy limits. To receive the lost income benefits, the covered person must have been an income producer in an occupational status at the time of the accident. When an insured had not yet reported to a summer job that was to start two days after the accident and had not yet earned any wages, the court upheld a jury verdict that the insured was not an income producer. This was the result in the Houston Court of Appeals [1st Dist.] 1981, opinion styled, Slocum v. United Pacific Insurance Co. The court did point out that “one does not have to be at work at the time of the accident to be in an occupational status.” Thus, one simply needs to commence earning income before the accident to be considered an income producer in an occupational status.

If the covered person was not employed, PIP benefits include expenses incurred for obtaining services that the covered person would have performed had they not been injured. If should be noted that the covered person must make an election as to whether he or she wishes to recover for lost income or the costs incurred in obtaining substitute services. He or she cannot recover both.

Personal Injury Protection – Coverage Answers

April 22, 2018 | Mark S. Humphreys

Personal Injury Protection (PIP) coverage is different than other types of injury coverage.

PIP coverage exists if the insured or their family member is struck by a “motor vehicle” designed for use mainly on public roads or a trailer of any type according to the 1984, Houston Court of Appeals [1st Dist.] opinion styled, National County Mutual Fire Insurance Co. v. Wallace. In Wallace, the court upheld a jury verdict that a forklift was a “motor vehicle” for purposes of PIP. This holding was based mainly on the fact that the particular forklift in question had been used on a public road, as specifically required in the PIP language.

PIP benefits consist of reasonable expenses incurred for necessary medical and funeral services as well as replacement of 80% of income lost during the period of disability up to the amount of PIP policy limits. To receive the lost income benefits, the covered person must have been an income producer in an occupational status at the time of the accident. When an insured had not yer reported to a summer job that was to start two days after the accident and had not yet earned any wages, the court upheld a jury verdict that the insured was not an income producer. This occurred in the 1981, Houston Court of Appeals [1st Dist.] opinion styled, Slocum v. United Pacific Insurance Company. The court did point out that “one does not have to be at work at the time of the accident to be in an occupational status.” Thus, one simply needs to commence earning income before the accident to be considered an income producer in an occupational status.

Auto Insurance – PIP – What Does “Occupying” Mean?

April 21, 2018 | Mark S. Humphreys

To be covered under most auto insurance Personal Injury Protection (PIP) provisions, a person needs to be “occupying” a vehicle.

“Covered person” as used in PIP coverage means the named insured or any family member while occupying or when struck by a motor vehicle designed for use maily on public roads or a trailer of any type. “Covered person” also includes any person occupying the covered auto with the named insured’s permission.

Most PIP claims arise out of accidents when an insured, a family member, and/or a friend of the insured are “occupying” an insured vehicle. The policy contains a very broad definition of “occupying.” For example, when an insured injured himself in the act of getting out of the car, the Fort Worth Court of Appeals held that the insured was “occupying” the vehicle. This was decided in 1976, and the case was styled, Berry v. Dairyland County Mutual Insurance Co.

What Is A “Motor Vehicle Accident” For Purposes Of P.I.P.

April 19, 2018 | Mark S. Humphreys

Personal Injury Protection or PIP is insurance that can be purchased with auto insurance . It is unique in its coverage.

One Texas court has construed “motor vehicle accident” narrowly in the context of PIP coverage. Specifically, it held that “motor vehicle accident” does not include all accidents that occur in a motor vehicle.

In the 1996, Houston Court of Appeals [1st Dist.] opinion styled, Schulz v. State Farm Mutual Automobile Insurance Co., Schulz’s passenger ordered him out of the truck and fatally shot him. The appeals court upheld summary judgment in favor of State Farm, which had denied coverage because PIP benefits provide for payment of damages as a result of “a motor vehicle accident.” According to the court a motor vehicle accident does not include all accidents that occur in a motor vehicle. Because there was no casual relationship between the vehicle and the victim’s death, there was no “motor vehicle accident.” Therefore, Schulz was not entitled to recover PIP benefits simply because a covered vehicle may have been used in his demise.

PIP

March 31, 2016 | Mark S. Humphreys

Insurance lawyers handling Personal Injury Protection (PIP) claims will find this article about Florida PIP claims to be interesting. While Florida laws are different than Texas PIP laws, they are not much different. Texas PIP laws are found in the Texas Insurance Code statutes beginning with 1952.151. And don’t forget that the Prompt Pay Statutes apply to PIP. This article from the Claims Journal is an article written to and for Florida insurers handling PIP claims and is insightful. The title of the article is, 10 Commandments for Insurers Responding to Florida PIP Demand Letters.

Under Florida law, a party seeking reimbursement of Personal Injury Protection (PIP) benefits must formally demand payment by the insurer before filing a lawsuit. Specifically, Florida Statute 627.736(10), in conjunction with other parts of the No Fault Law, outlines the procedures applicable to the submission and response to a demand letter. With that said, there are a myriad of factors to consider before preparing this response. Here are 10 commandments to guide you:

1. Read the demand letter carefully, including the attachments. You must figure out specifically what the demand letter is seeking. Not all demands are equal and an insufficient review of the plaintiff attorney’s demand could result in the insurer waiving certain defenses in its response.