US District Court holds medical review by PIP carrier not required when carrier disputes bill

McGovern Physical Therapy Associates provided physical therapy to a patient insured by Metropolitan for injuries he sustained in an auto accident. It submitted a request for PIP payment of $176 to Metropolitan.

Metropolitan paid McGovern $142.58, $34.42 less than the amount requested. It stated that "the amount allowed is based on provider charges within the provider's geographic region."

McGovern sued on behalf of itself and other providers, seeking reimbursement in all instances in which Metropolitan failed "to challenge the request for payment on its merits."

In McGovern Physical Therapy Assocs., LLC v. Metropolitan Property & Casualty Ins. Co., , the United States District Court for the District of Massachusetts denied McGovern's request to certify the case to the Supreme Judicial Court of Massachusetts. It held that the plain language of the PIP statute and the opinions of lower courts in Massachusetts "provide sufficient guidance" that its decision will not be "merely conjectural."

The court rejected McGovern's claim that the PIP statute requires review by a licensed practitioner, or a physical examination of the patient, whenever there is a dispute over the reasonableness of the charges. It held that a more plausible reading of the statute is that the review requirement applies only when the insurer denies a claim based upon an alleged lack of medical necessity for the services provided.