Navigating PIP Claims in Washington with a Legal Expert

Understanding PIP Insurance in Washington State

Personal Injury Protection, or PIP, is a mandatory component of auto insurance in Washington for most drivers. It is designed as a no-fault coverage, meaning it provides benefits to you and your passengers regardless of who caused the accident. The primary purpose is to offer swift financial assistance for medical expenses and lost wages, reducing the immediate burden after a collision and potentially preventing a rush to litigation.

Washington’s PIP law (RCW 48.22.085) requires insurers to offer a minimum of $10,000 in coverage per person, per accident. This coverage typically extends to:

Medical Expenses: Reasonable and necessary medical and hospital services, including ambulance rides, surgery, chiropractic care, physical therapy, and prosthetic devices.
Lost Wages: If injuries prevent you from working, PIP can cover 60% of your gross income or wages lost, up to a set monthly maximum.
Loss of Services: If you are injured and cannot perform household duties you would normally do (e.g., cleaning, childcare), PIP can pay for someone else to perform those services.
Funeral Expenses: A death benefit is available to cover costs associated with a fatal accident.

Coverage follows the individual, not just the vehicle. If you are a pedestrian struck by a car, or if you are injured while riding in someone else’s vehicle, your own PIP policy is typically the primary source of benefits.

Common Reasons for PIP Claim Denials and Delays

Despite its no-fault nature, insurers frequently deny, delay, or underpay PIP claims. Understanding these tactics is the first step in combating them.

Disputes over Medical Necessity: This is the most common reason for denial. An insurance adjuster, who is not a treating medical professional, may argue that certain treatments (like ongoing physical therapy or specific diagnostic tests) are not “reasonable and necessary.” They often rely on internal medical reviewers or software programs to make this determination.
Lateness of Claim: Washington law requires you to notify your insurance company of an accident “as soon as practicable.” While this isn’t a specific deadline, excessive delay can give the insurer grounds to deny the claim, arguing they were prejudiced by not being able to investigate promptly.
Failure to Attend an Independent Medical Examination (IME): The insurance policy is a contract that gives your insurer the right to request that you submit to a medical examination by a doctor of their choosing. Failure to attend this exam can result in an immediate suspension of benefits. It is critical to understand that the IME doctor is paid by the insurance company and their reports are often biased toward minimizing your injuries.
Pre-Existing Conditions: Insurers may investigate your medical history to argue that your current complaints are related to an old injury or condition, not the recent accident. They are not allowed to deny a claim solely based on a pre-existing condition; they must show that the accident did not aggravate or exacerbate it.
Policy Lapses and Coverage Disputes: If your premium wasn’t paid, your policy may have lapsed. Disputes can also arise over who is an “insured” under the policy or whether a specific vehicle was covered at the time of the accident.

The PIP Claims Process: A Step-by-Step Guide

Seek Immediate Medical Attention: Your health is the priority. This also creates a contemporaneous medical record linking your injuries to the accident. Follow all treatment recommendations from your doctors.
Notify Your Insurance Company: Report the accident to your auto insurance carrier immediately. Provide basic facts: date, time, location, and vehicles involved. Do not provide a detailed recorded statement about your injuries until you have consulted with an attorney.
Complete Application Forms: Your insurer will send you a PIP application package, including a Proof of Claim form, an Authorization to Obtain Medical Records, and often a Wage and Salary Verification form. It is imperative to complete these forms accurately and thoroughly. An attorney can ensure this is done correctly to avoid inadvertent misrepresentations.
Submit Ongoing Documentation: PIP is paid as expenses are incurred. You must submit all medical bills, explanations of benefits (EOBs) from your health insurance, and documentation of lost wages to your auto insurer on a continuous basis. Meticulous record-keeping is essential.
Cooperate with the Investigation: You have a contractual duty to cooperate, which includes providing requested documents and attending the IME. However, you have the right to have your attorney present for any examinations or complex communications.
Appeal a Denial: If your claim is denied or benefits are terminated, the insurer must provide a written explanation. This denial letter is crucial. You have the right to appeal the decision, a process that involves submitting additional medical evidence and legal arguments. This is where legal counsel becomes invaluable.

When and Why to Hire a Legal Expert

Many people believe a lawyer is only needed for the at-fault party’s liability insurance claim. This is a misconception. An experienced personal injury attorney is equally critical for navigating the PIP process with your own insurer.

An attorney ensures your rights are protected against bad faith tactics. Insurance companies have a legal duty under Washington’s Insurance Fair Conduct Act (IFCA) and the Consumer Protection Act (CPA) to act in good faith. Unreasonable delays, lowball offers, or unjust denials can constitute bad faith, for which you may be able to sue for damages that exceed your policy limits.

Legal expertise is crucial for navigating the Independent Medical Examination (IME). An attorney can:

Research the background and reputation of the IME doctor selected by the insurer.
Provide you with guidance on how to conduct yourself during the examination.
Ensure the IME report is properly scrutinized and challenged if it is biased, inaccurate, or incomplete. This often involves deposing the IME doctor and using opposing medical experts.

An attorney maximizes your recovery by properly coordinating benefits. If you have health insurance, Medicare, or Medicaid, PIP is primary. However, coordinating these payers and ensuring no liens are improperly asserted requires sophisticated knowledge of ERISA and federal law. An attorney ensures your PIP benefits are exhausted correctly before other insurance is tapped, preserving your health coverage for future needs.

Complex claims demand expert handling. If your injuries are severe, long-term, or involve significant wage loss, the value of your claim will quickly approach or exceed the $10,000 PIP limit. A lawyer will build the PIP claim with an eye toward the subsequent third-party claim against the at-fault driver, ensuring the medical narrative is strong and consistent.

Navigating the Independent Medical Examination (IME)

The IME is a common and critical juncture in a PIP claim where insurers often seek to cut off benefits. The chosen physician is paid thousands of dollars by the insurance company and understands their role is to find a reason to terminate payments.

Before the IME: Do not bring any medical records unless specifically instructed to in writing by your attorney. The doctor may misinterpret or selectively focus on unrelated prior complaints. Briefly review your medical history and the accident facts to be consistent, but do not rehearse.

During the IME: Be polite and truthful but succinct. Do not volunteer extra information. Answer only the question asked. Do not exaggerate your symptoms. If you are experiencing pain, describe it accurately. If asked about your daily activities, be honest but clarify that you are performing them in pain or with modifications. Do not allow the examination to exceed the scope agreed upon (e.g., a physical exam should not include psychologically probing questions unless it’s a psychiatric IME).

After the IME: Inform your attorney of everything that transpired. The IME report will be sent to the insurer and eventually to you and your lawyer. Your attorney will analyze it for bias, inaccuracies, and unsupported conclusions. If the report is flawed, your lawyer can demand continued benefits and, if necessary, use a rebuttal report from your treating physician to challenge its findings.

The Intersection of PIP and Third-Party Liability Claims

Your PIP claim is separate from, but intimately connected to, any claim you pursue against the driver who caused the accident. Your PIP insurer has a right to be reimbursed for the benefits it paid to you from any settlement or judgment you recover from the at-fault party. This is called subrogation.

Washington law (RCW 48.22.040) governs this reimbursement. However, your PIP insurer is not entitled to be paid back dollar-for-dollar if your overall recovery from the at-fault driver is insufficient to fully compensate you for all your damages. An attorney will negotiate the PIP lien to ensure it is reduced fairly, reflecting the insurer’s share of attorney’s fees and costs and protecting your full recovery for pain and suffering.

Strategically, the evidence gathered during the PIP process—medical records, bills, and expert opinions—forms the foundation of your liability claim. A well-documented PIP file demonstrates the extent and causation of your injuries, making it significantly harder for the at-fault party’s insurer to dispute your damages.

Your Rights and insurer Responsibilities: Avoiding Bad Faith

Washington law imposes a duty of good faith and fair dealing on insurers. This duty requires them to:

Conduct a prompt and thorough investigation of your claim.
Provide a reasonable explanation for denying a claim.
Base their decisions on adequate evidence and Washington law.
Not place their financial interests above those of their policyholder.

If an insurer violates this duty, you may have a cause of action for bad faith. Potential damages in a bad faith lawsuit can include:

The full value of the PIP benefits wrongfully withheld.
Emotional distress damages caused by the unreasonable denial.
attorneys’ fees and litigation costs under IFCA and the CPA.
Treble damages (up to three times the actual damages) under IFCA if the violation is unreasonable and continues after you provide them written notice of the claim.

Document every interaction with your insurance company. Keep a log of phone calls with names, dates, and summaries. Save all correspondence. This creates a paper trail that can prove a pattern of unreasonable behavior.