In an October 18th press release, Allstate announced that they agreed to a 10 million dollar regulatory settlement over the process in which they handle bodily injury claims.  The National Association of Insurance Commissioners (NAIC) completed an 18-month examination of Allstate's multi-state claims handling system.  Allstate has been using a software program called Colossus to guide them in making settlement offers after motor-vehicle accidents.  While the software has proven to be effective it was not being consistently modified or "tuned" for all of Allstate's regions.  According to the settlement, Allstate has agreed to make many changes, which include:

• Notifying claimants that the Colossus program may be used in adjusting their claims.
• Providing consistent updates in a uniform fashion for all regions including modifications that reflect recently settled claims.
• Consolidating it's bodily injury claims "handling practices" into a single manual.
• Not establishing any rules requiring claims adjusters to settle claims according to the value provided by Colossus
• Not offering incentive programs for adjusters who settle at the value suggested by Colossus.

This $10 million settlement will go into a regulatory fund for the 45 states that signed this agreement.  It will be used to help implement these new guidelines and properly train examiners in reviewing and monitoring software programs in their use of evaluating injury claims.

In Michigan, after a motor-vehicle accident, a person may be entitled to no-fault benefits, this includes any loss of wages or income. There's always been a maximum amount per month a victim can be paid from an auto insurance company for this benefit. Each year the Commissioner of Insurance for the State of Michigan adjusts this amount to reflect changes in the cost of living. This is usually calculated in August and takes effect on October first of that year. The monthly maximum work loss benefits payable under Michigan's no-fault law has just increased to $4,929 per month.  A person is eligible for these benefits for up to 3 years after the accident. To receive any excess wage, income or other economic loss, a person would need to pursue the third-party case against a potentially negligent driver.

See MCL 500.3107　

As you have learned this past month through my blogs, no-fault benefits may be payable in circumstances where you may not have thought they would be because the injury was not caused by a typical motor vehicle crash. However the injury DID involve a motor vehicle.

We know that in order for Michigan No Fault benefits to be payable you need to ask the following question: Was there an accidental injury that arose out of the ownership, operation, use or maintenance of the motor vehicle as a motor vehicle?　 If the answer is yes, then the Michigan motor vehicle injured victim may be entitled to no fault benefits.

Here are a few examples of unusual circumstances where benefits may still be payable:

Use of Motor Vehicle    

 As you have learned this past month through my blogs, no-fault benefits may be payable in circumstances where you may not have thought they would be because the injury was not caused by a typical motor vehicle crash. However the injury DID involve a motor vehicle.

 We know that in order for Michigan No Fault benefits to be payable you need to ask the following question: Was there an accidental injury that arose out of the ownership, operation, use or maintenance of the motor vehicle as a motor vehicle?  If the answer is yes, then the Michigan motor vehicle injured victim may be entitled to no fault benefits.

Here is an example of an unusual circumstance where benefits may still be payable:

Entering or Exiting (Slip & Fall):

• Patient getting in or out of vehicle and slips on ice, oil, etc.; usually entitled PIP.
  
• Patient fuels vehicle and falls after walking around to get back in; possible PIP coverage.
  
• Man falls from high step of truck after hand slips off of door handle. Entitled to PIP.

As you have learned this past month through my blogs, no-fault benefits may be payable in circumstances where you may not have thought they would be because the injury was not caused by a typical motor vehicle crash. However the injury DID involve a motor vehicle.

 We know that in order for Michigan No Fault benefits to be payable you need to ask the following question: Was there an accidental injury that arose out of the ownership, operation, use or maintenance of the motor vehicle as a motor vehicle?  If the answer is yes, then the Michigan motor vehicle injured victim may be entitled to no fault benefits.

Here is an example of an unusual circumstance where benefits may still be payable:

Loading & Unloading:

• A man loading or unloading a motor vehicle usually is entitled to PIP.
• If patient is loading a heavy bag of salt in his trunk and injures his back, he may be entitled to PIP.
• Man stacking boxes in back of a truck when a pallet falls on his head is entitled to PIP.
• Camper ladder collapses as man carries heavy cooler to roof. Entitled to PIP.

As you have learned this past month through my blogs, no-fault benefits may be payable in circumstances where you may not have thought they would be because the injury was not caused by a typical motor vehicle crash. However the injury DID involve a motor vehicle.

 We know that in order for Michigan No Fault benefits to be payable you need to ask the following question: Was there an accidental injury that arose out of the ownership, operation, use or maintenance of the motor vehicle as a motor vehicle?  If the answer is yes, then the Michigan motor vehicle injured victim may be entitled to no fault benefits.

Here are a few examples of unusual circumstances where benefits may still be payable:

Not Logical or Fair:

        Figuring out which or whose auto insurance company is obligated to pay medical bills and other PIP benefits can be confusing.  To determine which auto insurance company is responsible for paying benefits, answer the following questions:

1.  Was there an accidental injury that arose out of the ownership, operation,  use or maintenance of a motor vehicle as a motor vehicle? If answer is “Yes,  continue. 
     For an Insurance Company to be obligated to pay under the No-Fault Law a “motor vehicle” has to be “involved.”  This typically means a car, van, truck, trailer or bus was somehow involved in the accident. 
      A motorcycle is not defined as a motor vehicle under the No-Fault Law.  If patient was injured in a single motorcycle accident (e.g. biker hits tree, deer, or other motorcycle), no PIP benefits are available.  However, if a car cut the biker off, a “motor vehicle” was “involved” and benefits would be available.
 

2.  Do any exclusions apply? If no exclusions apply, continue.

• If the patient is an owner of an uninsured vehicle that was involved, he or she is not entitled to PIP.
• A patient that stole the accident vehicle is not entitled to PIP.
• A patient from a different state in a car registered in a different state MAY be excluded from benefits.
• If the patient's injury occurs while performing his job, worker's compensation insurance MAY pay some of the benefits that would normally be paid by the automobile insurance.

3.  Was the patient an “Occupant of a privately owned vehicle”, a

    Non-Occupant (pedestrian, bicyclist, etc.) or a Motorcyclist?
The determination as to which auto insurance company is responsible for PIP benefits is different for an occupant, non-occupant and motorcyclist.  The next three pages explain the process for determining which company is responsible.
 

IN A NUT SHELL:
1.                  A Motor Vehicle must be involved.
2.                  You don't get PIP if you stole the accident vehicle or are the owner of an uninsured motor vehicle involved in the accident.
3.                  You must figure out if patient is an Occupant, a Non-Occupant or a Motorcyclist to  ascertain which insurance company is responsible for paying PIP.
 

Here are a few examples of situations where No-Fault benefits must be paid, although the circumstances of the injury wouldn't normally make someone think they would be.

First let's look at the law which makes no fault benefits payable in a Michigan incident: the Michigan no-fault law states that

No Fault Benefits are payable to anyone who suffers an injury "arising out of* the ownership*, operation*, maintenance* or use* of a motor vehicle* as a motor vehicle*".

I have placed asterisks next to important words or phrases that have special meaning under Michigan's no-fault law. If the injury "arises out of" the "use" of a motor vehicle then no-fault benefits must be paid. An example of this is if you are getting out of your car, put 1 foot on the pavement, attempting to standup but your foot slips, you fall to the ground breaking your hip--- the analysis is your injury arose out of the use of your motor vehicle. Case law that has developed over the years has shown that getting in or out of your vehicle, as long as you're in very close proximity to it, justifies no-fault benefits being paid. This includes all of the medical bills for the injury.

Overview:

1. When should bills be paid by an auto carrier?

A: If a "Motor Vehicle" is "involved" in the accident, the injured person is entitled to First Party or PIP (Personal Injury Protection) benefits. This includes payment of medical bills.

2. What are First Party or PIP (Personal Injury Protection) benefits?

A: "First Party" or "PIP" are phrases used by the insurance industry for the claims opened for medical bills, up to three years of wage loss, up to three years of replacement services (household chores, a.k.a. essential services), medical mileage and attendant care. These claims are made against an automobile insurance company.

3. How do I set up a PIP claim so I can submit bills for payment?

A: Get an Application for Benefits Form from the appropriate Auto Insurance Company, have the patient fill it out and send it back. Many companies now don't bother with the Application for Benefits Form and just set up the claim over the phone by speaking to the patient. The assigned PIP adjuster will then contact the patient within days of the call with the claim number, address and instructions for obtaining benefits. The claim must be filed within one year after the accident.

4. How do I know which auto insurance company has to pay the bills?

A: The Michigan No Fault Act (MCLA 500.3101 et. seq.) sets forth the rules for determining which insurance company pays under different circumstances. These rules are detailed on the following pages entitled No-Fault PIP Priorities.