North Carolina Personal Injury and Proof of “Allowable Expenses” and No-Fault Benefits

Justice is based on proof. If you have been involved in a car accident in North Carolina, having records of your medical treatment and the costs is critical.
In addition to proper medical records, having an experienced North Carolina injury attorney can be the difference between winning and losing your case.

Armisted v. State Farm is a case involving six plaintiffs (plaintiffs) who suffered from serious injuries which were the result of their respective automobile accidents. Plaintiffs suffered catastrophic traumatic brain injuries and sought payment from their no-fault insurance company for the cost of having a home attendant care service. Initially, State Farm Mutual Automobile Insurance Company (State Farm) paid the plaintiff benefits at the rate the plaintiffs requested. There was a settlement agreement where State Farm agreed to pay each plaintiff the original amount for a definite period of time. However, after the time stipulated in the settlement agreement, and after conducting market survey research on cost of home attendant care service, State Farm reduced the benefit rates to the rates consistent with the market survey.

Plaintiff’s sued State Farm to make it pay benefits consistent with the original rate of benefits. State Farm argued that because plaintiffs refused to submit documentation proving the nature and extent of their expenditures, State Farm was not justified in paying the higher benefits. The reason why it was so critical for State Farm to have this information was that it needed to establish the exact type of injuries, the home care that was necessary, and how much that care would cost.

The cost of benefits paid by insurance companies to injured policyholders must be reasonable and consistent with the nature and extent of the care provided. State Farm acknowledges that the amount it was paying in benefits decreased substantially but it would be willing to pay additional hourly benefits if it received documentation demonstrating that this increase in benefit costs was justifiable.

Plaintiff’s countered, that because of the advice of counsel they were not to provide these documents to State Farm.

The jury found on behalf of State Farm because the plaintiffs failed to prove that the expenses of around the clock care were necessary and allowable.

The following law was used to analyze the facts of the case. The court stresses that the plaintiff has the burden of proving their entitlement to no-fault benefits. The court looks to the definition of “allowable expenses” and the three requirements in order to find healthcare allowable. Plaintiff must prove that the charge for the service was reasonable, the service and expenses were reasonably necessary, and that the expense was actually incurred. Payable insurance benefits in accidental bodily injury cases accrue when the treatment is received not when the injury occurred.

State Farm stressed that in our current times, payment for services is contingent on a documentation of the services rendered. The jury is responsible for making the decision of whether the plaintiff’s expenses were allowable and covered by no-fault statutes. Because there was no evidence provided by the plaintiffs, the jury relied on this failure of documentation.

Although the plaintiff’s alleged that State Farm was misstating the law surrounding documentation, the court found that the plaintiffs failed to satisfy their burden of proof and a judgment for State Farm was warranted.

If you have been injured contact North Carolina injury attorneys at Lee Law Offices to schedule a free appointment today. Call 800-887-1965.

Additional Resources:

Armisted, et al. v. State Farm Mutual Automobile Insurance Company, No. 09-2055/2113 (6th Cir. Apr. 12, 2012).

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