What Do I Do If the Insurance Company Stops Paying for My Medical Treatment?

You’ve been diligently following your doctor’s orders after your car accident. You’re going to physical therapy, getting the treatments you need to recover, and submitting the bills to the insurance company. Then, a letter arrives in the mail that makes your heart stop: a “Denial of Benefits.” The insurance company has decided to cut you off. They will no longer pay for your medical care, claiming it is no longer “reasonable” or “necessary.”

Suddenly, you’re faced with an impossible choice: stop the treatment you need to heal, or continue the treatment and risk drowning in a sea of medical debt. It’s a stressful, intimidating situation designed to make you feel powerless.

But you are not powerless. An insurance company’s opinion is not the final word on your medical care. You have the right to challenge their decision. Understanding why they do this and knowing the immediate steps to take is the key to fighting back and protecting both your health and your financial future.

Useful Information for You: In a Nutshell

• Don’t Panic and Don’t Stop Treatment: Your health comes first. If your doctor says you need the treatment, continue with it if you can while you fight the denial.
• Understand the Reason: The denial letter will state a reason, often that the care is no longer “reasonable and necessary.” This is usually based on a paper review by a doctor hired by the insurer.
• Contact Your Doctor Immediately: Inform your doctor about the denial. Ask them to write a detailed letter of medical necessity explaining why the ongoing treatment is crucial for your recovery.
• Formally Appeal the Decision: You have the right to appeal. Submit a formal appeal in writing, including the letter from your doctor and any other supporting evidence.
• Use Your Health Insurance: While you appeal, you can submit your medical bills to your personal health insurance to prevent them from going to collections.

Why Do Insurance Companies Cut Off Treatment?

An insurance company is a business, and its primary goal is to minimize costs.¹ Every physical therapy session and doctor’s visit is an expense they want to avoid. The most common reason they will give for cutting off benefits is that their internal medical consultant has determined your treatment is no longer “reasonable, necessary, and related” to the accident.

This decision is often made by a doctor who has never met you, never examined you, and has only reviewed a portion of your medical file. They may conclude that you should have recovered by now based on standardized charts, ignoring your individual condition and your own doctor’s expert opinion.

This is a tactic. They are hoping you will be too intimidated to fight back and will simply stop treating, which saves them money and weakens your overall personal injury claim.²

Your Immediate Action Plan: A Step-by-Step Guide

1. Review the Denial Letter Carefully

The letter must state the specific reason for the denial. Take note of the date of the letter and any deadlines it mentions for filing an appeal.

2. Talk to Your Doctor

This is your most important step. Your treating physician’s opinion holds far more weight than that of a hired-gun insurance doctor.

• Inform them that your PIP or third-party claim has been denied.
• Ask them to write a detailed letter or report that specifically refutes the insurance company’s reasoning.
• This letter should clearly state that your treatment is, in their professional medical opinion, both necessary for your recovery and a direct result of the car accident.

3. File a Formal Appeal in Writing

Do not just argue with the adjuster on the phone. You must create a paper trail.

• Write a formal letter to the insurance adjuster stating that you are appealing their decision to deny your medical benefits.
• State that you are under the ongoing care of your doctor and are following their prescribed treatment plan.
• Attach the letter of medical necessity from your own doctor.
• Send the appeal via certified mail so you have proof that they received it.

4. Use Your Other Insurance Benefits

While the appeal is pending, you need to make sure your bills don’t go to collections.

• Personal Health Insurance: Submit your medical bills to your personal health insurance carrier. They will typically pay the bills and then seek reimbursement from the auto insurer if your appeal is successful.
• Personal Injury Protection (PIP): If it was your own PIP coverage that was denied, this appeal process is crucial. If it was the at-fault driver’s insurance, your own PIP may still provide coverage.

When to Get a Lawyer Involved

The moment an insurance company starts denying necessary medical care is the moment you should strongly consider getting professional legal help. An experienced car accident attorney can take over the entire process for you. They can:

• Handle the appeal process and all communication with the insurer.
• Work directly with your doctors to get the powerful documentation needed.
• Hire outside medical experts to review your case if necessary.
• File a complaint with the Washington State Insurance Commissioner for “bad faith” if the insurer is acting unreasonably.

You should not have to choose between your health and your financial stability. If an insurance company has cut off your medical benefits after a car accident in the Tacoma area, search the Car Accident Lawyer Directory Tacoma. Compare profiles and read real client reviews to find a trusted advocate who can fight to get your treatment reinstated and protect the full value of your claim.

References

• Washington State Office of the Insurance Commissioner (OIC) – Appealing a denied claim:

  The official consumer guide from the OIC, explaining your rights and the steps to take when an insurance company denies your claim.

  https://www.insurance.wa.gov/what-do-if-your-claim-denied-or-you-disagree-settlement-offer

• Washington Administrative Code (WAC 284-30-300s) – Unfair property/casualty claims settlement practices:

  The official state regulations that govern how insurance companies must handle claims, defining unfair practices like denying a claim without a reasonable investigation.3

  https://apps.leg.wa.gov/WAC/default.aspx?cite=284-30

• Washington State Legislature – RCW 48.30.015 – Unfair practices with respect to insurance claims:

  The state law that defines unfair and deceptive acts in the business of insurance, which can apply to wrongful denials of treatment.

  https://app.leg.wa.gov/RCW/default.aspx?cite=48.30.015