In Viruet v. Maoine, plaintiff was injured in a motor vehicle accident, and alleged that he incurred medical bills in the amount of $56,321.93.  The defendant, who was insured by GEICO with limited PIP medical coverage benefits of $15,000, argued that plaintiff’s claim for medical expenses (which obviously exceeded his limited PIP coverage benefits) were subject to the NJ Medical Fee Schedule under statute.

Defendant further argued that the boardable medical expenses to be considered by the jury were limited to the Fee Schedule amounts for the medical services provided to plaintiff. The NJ Fee Schedule limits medical costs and is a comprehensive listing of fee maximums used to reimburse physicians on a fee-for-service basis.

The court found that payment is due and owed from the plaintiff with respect to medical expenses exceeding coverage limits. Because the PIP carrier is not paying the medical expenses above the coverage limit, the Fee Schedule does not apply to the expenses outside the coverage and the medical provider may bill the patient for the full cost of treatment. The patient is personally responsible for the amount billed, including the portion in excess of the fee schedule.

As such, the court disagreed with the defendant, holding that a plaintiff who is awarded a verdict is entitled to payment for medical expenses which were reasonably required for the examination, treatment and care of injuries proximately caused by the defendant’s negligence. Further, plaintiff may recover the “fair and reasonable value of such medical expenses.” The court opined that under these circumstances, plaintiff would only be recovering his actual loss, not a windfall, as the medical expenses reflect the amount owed to the medical providers.  Thanks to Steve Kim for his contribution to this post.  Please email Brian Gibbons with any questions.