Personal Injury Protection Benefits
742.518 Definitions for ORS 742.518 to 742.542
742.520 Personal injury protection benefits for motor vehicle liability policies; applicability
742.521 Conditions applicable to arbitration proceedings
742.522 Binding arbitration under ORS 742.520; costs
742.524 Contents of personal injury protection benefits; deductibles
742.525 Provider charges
742.526 Primary nature of benefits
742.528 Notice of denial of payment of benefits
742.529 Payment based on incorrect determination of responsibility; notice; repayment
742.530 Exclusions from coverage
742.532 Benefits may be more favorable than those required by ORS 742.520, 742.524 and 742.530
742.534 Reimbursement of other insurers paying benefits; arbitrating issues of liability and amount of reimbursement
742.536 Notice of claim or legal action to insurer; insurer to elect manner of recovery of benefits furnished; lien of insurer
742.538 Subrogation rights of insurers to certain amounts received by claimant; recovery actions against persons causing injury
742.540 Rules
742.542 Effect of personal injury protection benefits paid
742.544 Reimbursement for personal injury protection benefits paid
742.546 Required disclosure in release for bodily injuries related to personal injury protection benefits
742.548 Required language in disclosure; conditions for rescission of release
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742.518 Definitions for ORS 742.518 to 742.542. As used in ORS 742.518 to 742.542:
(1) “Evaluation services” means physical examinations or reviews of medical records of beneficiaries conducted at the request of an insurer by either an employee of the insurer or a third-party medical record or bill review service to determine whether the provision or continuation of medical services is necessary or reasonable.
(2) “Managed care services” means any system of health care delivery that attempts to control or coordinate use of health care services in order to contain health care expenditures or improve quality of health care services.
(3) “Motor vehicle” means a self-propelled land motor vehicle or trailer, other than:
(a) A farm-type tractor or other self-propelled equipment designed for use principally off public roads, while not upon public roads;
(b) A vehicle operated on rails or crawler-treads; or
(c) A vehicle located for use as a residence or premises.
(4) “Motorcycle” and “moped” have the meanings given those terms in ORS 801.345 and 801.365.
(5) “Occupying” means in, or upon, or entering into or alighting from.
(6) “Pedestrian” means a person while not occupying a self-propelled vehicle other than a wheelchair or a similar low-powered motorized or mechanically propelled vehicle that is designed specifically for use by a person with a physical disability and that is determined to be medically necessary for the occupant of the wheelchair or other low-powered vehicle.
(7) “Personal injury protection benefits” means the benefits described in ORS 742.518 to 742.542.
(8) “Private passenger motor vehicle” means a four-wheel passenger or station wagon type motor vehicle not used as a public or livery conveyance, and includes any other four-wheel motor vehicle of the utility, pickup body, sedan delivery or panel truck type not used for wholesale or retail delivery other than farming, a self-propelled mobile home and a farm truck.
(9) “Proof of loss” means documentation that allows an insurer to determine whether a person is entitled to personal injury protection benefits and the amount of any benefit that is due.
(10) “Provider” has the meaning given that term in ORS 743.801. [2005 c.465 §2; 2007 c.70 §318; 2007 c.692 §1]
742.520 Personal injury protection benefits for motor vehicle liability policies; applicability. (1) Every motor vehicle liability policy issued for delivery in this state that covers any private passenger motor vehicle shall provide personal injury protection benefits to the person insured thereunder, members of that person’s family residing in the same household, children not related to the insured by blood, marriage or adoption who are residing in the same household as the insured and being reared as the insured’s own, passengers occupying the insured motor vehicle and pedestrians struck by the insured motor vehicle.
(2) Personal injury protection benefits apply to a person’s injury or death resulting:
(a) In the case of the person insured under the policy and members of that person’s family residing in the same household, from the use, occupancy or maintenance of any motor vehicle, except the following vehicles:
(A) A motor vehicle, including a motorcycle or moped, that is owned or furnished or available for regular use by any of such persons and that is not described in the policy;
(B) A motorcycle or moped which is not owned by any of such persons, but this exclusion applies only when the injury or death results from such person’s operating or riding upon the motorcycle or moped; and
(C) A motor vehicle not included in subparagraph (A) or (B) of this paragraph and not a private passenger motor vehicle. However, this exclusion applies only when the injury or death results from such person’s operating or occupying the motor vehicle.
(b) In the case of a passenger occupying or a pedestrian struck by the insured motor vehicle, from the use, occupancy or maintenance of the vehicle.
(3) Personal injury protection benefits consist of payments for expenses, loss of income and loss of essential services as provided in ORS 742.524.
(4) An insurer shall pay all personal injury protection benefits promptly after proof of loss has been submitted to the insurer.
(5) The potential existence of a cause of action in tort does not relieve an insurer from the duty to pay personal injury protection benefits.
(6) Disputes between insurers and beneficiaries about the amount of personal injury protection benefits, or about the denial of personal injury protection benefits, shall be decided by arbitration if mutually agreed to at the time of the dispute. Arbitration under this subsection shall take place as described in ORS 742.521.
(7) An insurer:
(a) May not enter into or renew any contract that provides, or has the effect of providing, managed care services to beneficiaries.
(b) May enter into or renew any contract that provides evaluation services for beneficiaries. [Formerly 743.800; 1991 c.768 §6; 1993 c.282 §1; 1993 c.596 §39; 1995 c.658 §114; 1997 c.344 §§1,2; 1997 c.808 §§3,4; 1999 c.434 §1; 2003 c.813 §1; 2005 c.465 §3; 2007 c.328 §8]
742.521 Conditions applicable to arbitration proceedings. (1) Arbitration proceedings under ORS 742.520 shall be conducted under local court rules in the county where the arbitration is held.
(2) Findings and awards made in an arbitration proceeding under this section:
(a) Are binding on the parties to the arbitration proceeding;
(b) Are not binding on any other party; and
(c) May not be used for the purpose of collateral estoppel. [2007 c.328 §3]
Note: 742.521 was added to and made a part of ORS chapter 742 by legislative action but was not added to any smaller series therein. See Preface to Oregon Revised Statutes for further explanation.
742.522 Binding arbitration under ORS 742.520; costs. (1) Costs to the insured of the arbitration proceeding under ORS 742.520 (6) shall not exceed $100 and all other costs of arbitration shall be borne by the insurer.
(2) As used in this section, “costs” does not include attorney fees or expenses incurred in the production of evidence or witnesses or the making of transcripts of the arbitration proceedings. [Formerly 743.802; 2007 c.328 §9]
742.524 Contents of personal injury protection benefits; deductibles. (1) Personal injury protection benefits as required by ORS 742.520 shall consist of the following payments for the injury or death of each person:
(a) All reasonable and necessary expenses of medical, hospital, dental, surgical, ambulance and prosthetic services incurred within one year after the date of the person’s injury, but not more than $15,000 in the aggregate for all such expenses of the person. Expenses of medical, hospital, dental, surgical, ambulance and prosthetic services shall be presumed to be reasonable and necessary unless the provider is given notice of denial of the charges not more than 60 calendar days after the insurer receives from the provider notice of the claim for the services. At any time during the first 50 calendar days after the insurer receives notice of claim, the provider shall, within 10 business days, answer in writing questions from the insurer regarding the claim. For purposes of determining when the 60-day period provided by this paragraph has elapsed, counting of days shall be suspended if the provider does not supply written answers to the insurer within 10 days and may not resume until the answers are supplied.
(b) If the injured person is usually engaged in a remunerative occupation and if disability continues for at least 14 days, 70 percent of the loss of income from work during the period of the injured person’s disability until the date the person is able to return to the person’s usual occupation. This benefit is subject to a maximum payment of $3,000 per month and a maximum payment period in the aggregate of 52 weeks. As used in this paragraph, “income” includes but is not limited to salary, wages, tips, commissions, professional fees and profits from an individually owned business or farm.
(c) If the injured person is not usually engaged in a remunerative occupation and if disability continues for at least 14 days, the expenses reasonably incurred by the injured person for essential services that were performed by a person who is not related to the injured person or residing in the injured person’s household in lieu of the services the injured person would have performed without income during the period of the person’s disability until the date the person is reasonably able to perform such essential services. This benefit is subject to a maximum payment of $30 per day and a maximum payment period in the aggregate of 52 weeks.
(d) All reasonable and necessary funeral expenses incurred within one year after the date of the person’s injury, but not more than $5,000.
(e) If the injured person is a parent of a minor child and is required to be hospitalized for a minimum of 24 hours, $25 per day for child care, with payments to begin after the initial 24 hours of hospitalization and to be made for as long as the person is unable to return to work if the person is engaged in a remunerative occupation or for as long as the person is unable to perform essential services that the person would have performed without income if the person is not usually engaged in a remunerative occupation, but not to exceed $750.
(2) With respect to the insured person and members of that person’s family residing in the same household, an insurer may offer forms of coverage for the benefits required by subsection (1)(a), (b) and (c) of this section with deductibles of up to $250. [Formerly 743.805; 1991 c.768 §7; 2003 c.813 §2; 2005 c.341 §1; 2009 c.66 §1]
742.525 Provider charges. (1) Except as provided in subsection (2) of this section, a provider shall charge a person who receives personal injury protection benefits or that person’s insurer the lesser of:
(a) An amount that does not exceed the amount the provider charges the general public; or
(b) An amount that does not exceed the fee schedules for medical services published pursuant to ORS 656.248 for expenses of medical, hospital, dental, surgical and prosthetic services.
(2) For expenses of hospital services that are subject to the adjusted cost-to-charge ratio specified for a hospital in the hospital fee schedule published pursuant to ORS 656.248, a provider of hospital services shall charge a person who receives personal injury protection benefits or that person’s insurer the greater of:
(a) The amount of the hospital charges multiplied by the adjusted cost-to-charge ratio specified for the hospital; or
(b) Ninety percent of the hospital charges. [2003 c.813 §4; 2005 c.341 §4; 2011 c.707 §1]
Note: 742.525 was added to and made a part of 742.518 to 742.542 by legislative action but was not added to any smaller series therein. See Preface to Oregon Revised Statutes for further explanation.
742.526 Primary nature of benefits. (1) The personal injury protection benefits with respect to:
(a) The insured and members of the family of the insured residing in the same household injured while occupying the insured motor vehicle shall be primary.
(b) Passengers injured while occupying the insured motor vehicle shall be primary.
(c) The insured and members of family residing in the same household injured as pedestrians shall be primary.
(d) The insured and members of family residing in the same household injured while occupying a motor vehicle not insured under the policy shall be excess.
(e) Pedestrians injured by the insured motor vehicle, other than the insured and members of family residing in the same household, shall be excess over any other collateral benefits to which the injured person is entitled, including but not limited to insurance benefits, governmental benefits or gratuitous benefits.
(2) The personal injury protection benefits may be reduced or eliminated, if it is so provided in the policy, when the injured person is entitled to receive, under the laws of this state or any other state or the United States, workers’ compensation benefits or any other similar medical or disability benefits. [Formerly 743.810]
742.528 Notice of denial of payment of benefits. An insurer who denies payment of personal injury protection benefits to or on behalf of an insured shall:
(1) Provide written notice of the denial, within 60 calendar days of receiving a claim from the provider, to the insured, stating the reason for the denial and informing the insured of the method for contesting the denial; and
(2) Provide a copy of the notice of the denial, within 60 calendar days of receiving a claim from the provider, to a provider of services under ORS 742.524 (1)(a). [Formerly 743.812; 1993 c.265 §1]
742.529 Payment based on incorrect determination of responsibility; notice; repayment. If personal injury protection benefits are paid based on information that appeared to establish proof of loss and the insurer paying the benefits later determines the insurer was not responsible for the payment, the insurer shall give notice and explanation to the provider that the payment was incorrectly issued. Immediately after receiving the notice and explanation the provider shall promptly repay the insurer. [2007 c.692 §3]
Note: 742.529 was added to and made a part of 742.518 to 742.542 by legislative action but was not added to any smaller series therein. See Preface to Oregon Revised Statutes for further explanation.
742.530 Exclusions from coverage. (1) The insurer may exclude from the coverage for personal injury protection benefits any injured person who:
(a) Intentionally causes self-injury;
(b) Is participating in any prearranged or organized racing or speed contest or practice or preparation for any such contest; or
(c) Willfully conceals or misrepresents any material fact in connection with a claim for personal injury protection benefits.
(2) The insurer may exclude from the coverage for the benefits required by ORS 742.524 (1)(b) and (c) any person injured as a pedestrian in an accident outside this state, other than the insured person or a member of that person’s family residing in the same household. [Formerly 743.815; 2005 c.341 §2]
742.532 Benefits may be more favorable than those required by ORS 742.520, 742.524 and 742.530. Nothing in ORS 742.518 to 742.542 is intended to prevent an insurer from providing more favorable benefits than the personal injury protection benefits described in ORS 742.520, 742.524 and 742.530. [Formerly 743.820]
742.534 Reimbursement of other insurers paying benefits; arbitrating issues of liability and amount of reimbursement. (1) Except as provided in ORS 742.544, every authorized motor vehicle liability insurer whose insured is or would be held legally liable for damages for injuries sustained in a motor vehicle accident by a person for whom personal injury protection benefits have been furnished by another such insurer, or for whom benefits have been furnished by an authorized health insurer, shall reimburse such other insurer for the benefits it has so furnished if it has requested such reimbursement, has not given notice as provided in ORS 742.536 that it elects recovery by lien in accordance with that section and is entitled to reimbursement under this section by the terms of its policy. Reimbursement under this subsection, together with the amount paid to injured persons by the liability insurer, shall not exceed the limits of the policy issued by the insurer.
(2) In calculating such reimbursement, the amount of benefits so furnished shall be diminished in proportion to the amount of negligence attributable to the person for whom benefits have been so furnished, and the reimbursement shall not exceed the amount of damages legally recoverable by the person.
(3) Disputes between insurers as to such issues of liability and the amount of reimbursement required by this section shall be decided by arbitration.
(4) Findings and awards made in such an arbitration proceeding are not admissible in any action at law or suit in equity.
(5) If an insurer does not request reimbursement under this section for recovery of personal injury protection payments, then the insurer may only recover personal injury protection payments under the provisions of ORS 742.536 or 742.538. [Formerly 743.825; 1993 c.709 §7; 2007 c.392 §1]
742.536 Notice of claim or legal action to insurer; insurer to elect manner of recovery of benefits furnished; lien of insurer. (1) When an authorized motor vehicle liability insurer has furnished personal injury protection benefits, or an authorized health insurer has furnished benefits, for a person injured in a motor vehicle accident, if such injured person makes claim, or institutes legal action, for damages for such injuries against any person, such injured person shall give notice of such claim or legal action to the insurer by personal service or by registered or certified mail. Service of a copy of the summons and complaint or copy of other process served in connection with such a legal action shall be sufficient notice to the insurer, in which case a return showing service of such notice shall be filed with the clerk of the court but shall not be a part of the record except to give notice.
(2) The insurer may elect to seek reimbursement as provided in this section for benefits it has so furnished, out of any recovery under such claim or legal action, if the insurer has not been a party to an interinsurer reimbursement proceeding with respect to such benefits under ORS 742.534 and is entitled by the terms of its policy to the benefit of this section. The insurer shall give written notice of such election within 30 days from the receipt of notice or knowledge of such claim or legal action to the person making claim or instituting legal action and to the person against whom claim is made or legal action instituted, by personal service or by registered or certified mail. In the case of a legal action, a return showing service of such notice of election shall be filed with the clerk of the court but shall not be a part of the record except to give notice to the claimant and the defendant of the lien of the insurer.
(3) If the insurer so serves such written notice of election and, where applicable, such return is so filed:
(a) The insurer has a lien against such cause of action for benefits it has so furnished, less the proportion, not to exceed 100 percent, of expenses, costs and attorney fees incurred by the injured person in connection with the recovery that the amount of the lien before such reduction bears to the amount of the recovery.
(b) The injured person shall include as damages in such claim or legal action the benefits so furnished by the insurer.
(c) In the case of a legal action, the action shall be taken in the name of the injured person.
(4) As used in this section, “makes claim” or “claim” refers to a written demand made and delivered for a specific amount of damages and which meets other requirements reasonably established by the director’s rule. [Formerly 743.828]
742.538 Subrogation rights of insurers to certain amounts received by claimant; recovery actions against persons causing injury. If a motor vehicle liability insurer has furnished personal injury protection benefits, or a health insurer has furnished benefits, for a person injured in a motor vehicle accident, and the interinsurer reimbursement benefit of ORS 742.534 is not available under the terms of that section, and the insurer has not elected recovery by lien as provided in ORS 742.536, and is entitled by the terms of its policy to the benefit of this section:
(1) The insurer is entitled to the proceeds of any settlement or judgment that may result from the exercise of any rights of recovery of the injured person against any person legally responsible for the accident, to the extent of such benefits furnished by the insurer less the insurer’s share of expenses, costs and attorney fees incurred by the injured person in connection with such recovery.
(2) The injured person shall hold in trust for the benefit of the insurer all such rights of recovery which the injured person has, but only to the extent of such benefits furnished.
(3) The injured person shall do whatever is proper to secure, and shall do nothing after loss to prejudice, such rights.
(4) If requested in writing by the insurer, the injured person shall take, through any representative not in conflict in interest with the injured person designated by the insurer, such action as may be necessary or appropriate to recover such benefits furnished as damages from such responsible person, such action to be taken in the name of the injured person, but only to the extent of the benefits furnished by the insurer. In the event of a recovery, the insurer shall also be reimbursed out of such recovery for the injured person’s share of expenses, costs and attorney fees incurred by the insurer in connection with the recovery.
(5) In calculating respective shares of expenses, costs and attorney fees under this section, the basis of allocation shall be the respective proportions borne to the total recovery by:
(a) Such benefits furnished by the insurer; and
(b) The total recovery less (a).
(6) The injured person shall execute and deliver to the insurer such instruments and papers as may be appropriate to secure the rights and obligations of the insurer and the injured person as established by this section.
(7) Any provisions in a motor vehicle liability insurance policy or health insurance policy giving rights to the insurer relating to subrogation or the subject matter of this section shall be construed and applied in accordance with the provisions of this section. [Formerly 743.830]
742.540 Rules. The Director of the Department of Consumer and Business Services shall have authority to issue such rules as are reasonably necessary to carry out the purposes of ORS 742.518 to 742.542. [Formerly 743.833]
742.542 Effect of personal injury protection benefits paid. Payment by a motor vehicle liability insurer of personal injury protection benefits for its own insured shall be applied in reduction of the amount of damages that the insured may be entitled to recover from the insurer under uninsured or underinsured motorist coverage for the same accident but may not be applied in reduction of the uninsured or underinsured motorist coverage policy limits. [Formerly 743.835; 1997 c.808 §10]
742.544 Reimbursement for personal injury protection benefits paid. (1) A provider of personal injury protection benefits shall be reimbursed for personal injury protection payments made on behalf of any person only to the extent that the total amount of benefits paid exceeds the economic damages as defined in ORS 31.710 suffered by that person. As used in this section, “total amount of benefits” means the amount of money recovered by a person from:
(a) Applicable underinsured motorist benefits described in ORS 742.502 (2);
(b) Liability insurance coverage available to the person receiving the personal injury protection benefits from other parties to the accident;
(c) Personal injury protection payments; and
(d) Any other payments by or on behalf of the party whose fault caused the damages.
(2) Nothing in this section requires a person to repay more than the amount of personal injury protection benefits actually received. [1993 c.709 §9]
742.546 Required disclosure in release for bodily injuries related to personal injury protection benefits. (1) When a motor vehicle liability insurer obtains a release for bodily injuries within 60 calendar days following an accident from a person who is eligible to receive personal injury protection benefits under ORS 742.518 to 742.542, the release must state that, subject to the motor vehicle liability insurer’s applicable limits of liability, the rights of an insurer furnishing personal injury protection to recover payments made for medical benefits from the motor vehicle liability insurer are not impaired.
(2) Nothing in this section impairs the rights of a motor vehicle liability insurer to contest a recovery claim from an insurer furnishing personal injury protection, based upon liability or the reasonableness or necessity of medical benefits paid by the insurer furnishing personal injury protection. [2009 c.545 §2]
Note: 742.546 and 742.548 were added to and made a part of the Insurance Code by legislative action but were not added to ORS chapter 742 or any series therein. See Preface to Oregon Revised Statutes for further explanation.
742.548 Required language in disclosure; conditions for rescission of release. If a representative of a motor vehicle liability insurer obtains a release for a claim of bodily injuries in person from a person who is eligible to receive personal injury protection benefits under ORS 742.518 to 742.542:
(1) The representative of the insurer must provide the eligible person with a clear and conspicuous notice substantially similar to the following, which shall be incorporated into the insurer’s release or provided in a separate document:
______________________________________________________________________________
THE DOCUMENT YOU ARE BEING ASKED TO SIGN IS A BINDING CONTRACT THAT CONCLUDES YOUR CLAIM(S) AGAINST THE PARTIES IT IDENTIFIES. AFTER YOU SIGN IT YOU WILL NOT BE ABLE TO MAKE ANY FURTHER CLAIM(S) AGAINST THESE PARTIES.
______________________________________________________________________________
(2) The eligible person may rescind the release if the person provides the insurer written notice of rescission no later than five business days after the execution of the release and then promptly performs all other requisite acts for rescission of a contract. For the purposes of this subsection, notice of rescission is provided to an insurer on the date and time shown on a properly addressed proof of mailing or electronic transmission. [2009 c.545 §3]
Note: See note under 742.546.