The New Jersey Law Journal reports that a Mercer County Superior Court Judge has overturned a PIP arbitrator’s decision denying a plaintiff, called I.R. in court papers, an emergent hearing on whether her auto insurance carrier must pay for exploratory surgery. Serious insurance issues usually arise in the context of auto accidents; therefore, anyone involved in an auto accident in New Jersey should contact a New Jersey personal injury lawyer or a New Jersey auto accident lawyer for a consultation.
I.R. was involved in an auto accident in 1999 and she suffered serious injuries to her back and neck as a result of that accident. As a result, I.R. was required to undergo several surgeries to her neck and back, including a fusion of several vertebrae. In 2003, I.R. was involved in another auto accident and as a result of that accident, pain again began to flare up in her beck and neck. The pain got so bad that I.R. began to contemplate suicide. I.R. consulted with a surgeon, who recommended exploratory surgery to determine whether the earlier spinal fusion had failed.
I.R. requested pre-certification from her auto insurance company, 21st Century Insurance, part of AIG, that they would pay for the expensive surgery, which was estimated to cost upwards of $100,000. Her insurance company denied coverage. Soon thereafter, I.R. filed an appeal of the denial of coverage with the National Arbitration Forum, which is New Jersey’s PIP arbitration provider. I.R.’s lawyer requested that the case be heard on an emergent basis, which would provide a resolution within days, rather than the 6 to 8 months normally required for PIP arbitration. I.R.’s surgeon was prepared to testify before the arbitrator that the longer the surgery was delayed, the less likely it would be successful.
Citing the delay between the date that I.R.’s surgeon first recommended the exploratory surgery, which was in October 2008 and the date on which the request for an emergent hearing was filed, which was in February 2009, the arbitrator determined that an emergent hearing was not warranted in this case. I.R. filed an appeal of the arbitrator’s decision in Superior Court and argued that the decision of the arbitrator was arbitrary and capricious, contrary to law, factually mistaken and a denial of due process. The Superior Court, after determining that the decision of the arbitrator was “shocking” and “grossly insufficient,” agreed and sent the case back to the National Arbitration Forum for an emergent hearing. The result of the emergent hearing was a decision on May 6, 2009 that the exploratory surgery was covered an I.R.’s auto insurance carrier would have to pay for the surgery.
This case came to prominence because it highlighted some of the problems with the PIP arbitration process, which has come under attack lately because, in many cases, injured parties are forced to wait a long time for decisions on whether they can get insurance coverage for necessary treatments or diagnostic tests for their injuries. Anyone injured in an auto accident in New Jersey should contact a New Jersey personal injury lawyer or New Jersey auto accident lawyer for assistance.
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