Kentucky Supreme Court Says Insurers Cannot Deny PIP/BRB Based on Medical Records Reviews

On November 1, 2018, in the case of GEICO v. Sanders, et al. (2016-SC-000546-DG), the Kentucky Supreme Court issued an opinion in which it decided that PIP/BRB Obligors cannot deny benefits based solely upon medical records reviews. The Court held that the PIP/BRB Obligor’s assertion that it should have the right to deny payment of a claimant’s medical treatment based on a paper review of the medical record after the treatment had been rendered is inconsistent with subsections 2, 3, 5 and 7 of KRS 304.39-010’s statement of policy and purpose. All these subsections are concerned with making sure injured victims get prompt medical treatment and rehabilitation with prompt payment and simplified procedures.

Based upon a presumption of reasonableness, the Court reasoned that “since a legal presumption must be overcome in order to deny a medical bill or expenses, an action would have to be filed with the courts and the BRB/PIP Obligor would be required to present evidence to rebut said presumption.” As such, because the bills are presumed reasonable, this would prevent a BRB/PIP obligor from unilaterally denying medical treatment or bills based upon a paper review of records.

At the core of the Opinion, the Court found the purpose of the Kentucky MVRA is to provide prompt medical treatment and rehabilitation. The medical treatments and invoices are presumed to be reasonable. It requires prompt payment and recovery of any improper payment must be accomplished by filing an action in court. The BRB/PIP obligor may file a lawsuit against the party who made the misrepresentation of a material fact causing the improper payment.

It remains important for insurers to retain experienced defense attorneys to navigate this ever-changing area of law. If you are an insurance provider, and would like to know more about Kentucky’s Motor Vehicle Reparations Act, contact our office at 859.422.6000.

Read the full opinion here. 

Summary authored by WHT attorney Max Smith. Learn more about Max and his practice by visiting his bio. 

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