During an examination under oath (“EUO”), an insurance company requests that a patient appear before an attorney and/or an investigator to answer questions under oath relating to a no-fault claim.
The patient, who is entitled to representation by an attorney at the EUO, can be questioned about a range of topics. These topics include, but are not limited to, prior injuries, circumstances surrounding the accident, his or her present medical condition, and treatment. Usually, by the time the EUO is conducted, the insurance company has already received bills from the patient’s treating physician, and will question the patient as to whether they received the same treatment as those reflected in the billing.
An insurance company has the right to demand an EUO of the patient as a means to verify a no-fault claim. This right was given to insurance companies in the revised No-Fault Regulations of 2002, which state that “[u]pon request by [an insurance company], the eligible injured person or that person’s assignee or representative shall . . . as may reasonably be required submit to examination under oath by any person named by the [insurance company] and subscribe same.”
Scheduling of an Examination Under Oath
There are various provisions within the No-Fault Law that an insurance company must follow when scheduling an EUO of a patient. Proper mailing of the notice is often an issue of contention. However, it should be noted that insurance companies are under no obligation to advise a treating physician that an EUO of the patient is scheduled.
The content of the letters is critical as well. An EUO must be scheduled for a time and in a place and location that is reasonably convenient for the patient. Specifically, proper scheduling letters should:
- Give the patient at least two weeks’ notice of the EUO date;
- Set the EUO at a place within the same county in which the patient resides; and
- Apprise the patient that he or she is entitled to be reimbursed for reasonable transportation costs and lost earnings incurred due to his or her attendance.
Additionally, because insurance companies must request verification of a claim not once but twice before denying that claim, an insurance company is obligated to provide a patient with two opportunities to attend an EUO. That is, if a patient fails to appear for the first EUO, an insurance company has an obligation to schedule a second appearance. If the patient fails to appear for the second scheduled EUO, an insurance company then has the right to deny the claim.
Consequences for Failure to Attend an EUO
It is well-settled that a patient’s unexcused failure to comply with a demand for an EUO (i.e., failure to attend two properly scheduled EUOs) is a policy violation and grounds for an insurance company’s disclaimer of the patient’s no-fault benefits.
Because an EUO is a form of verification and is deemed received on the date of the “missed EUO,” the insurance company should deny the claim within thirty days of the patient’s failure to appear for the second EUO.
Consequences for Treating Physicians
It is important that a physician understand that if his or her patient fails to appear for two properly scheduled EUOs, an insurance company may have grounds to deny a claim retroactively to the date of loss. In some jurisdictions, an insurance company is even allowed to amend a previous denial and/or assert an otherwise late denial to include the defense of missed EUOs.
A patient’s missed EUOs is often fatal to the treating physician’s claim for reimbursement. Unfortunately and unfairly, scenarios arise where a physician provides medically necessary treatment to a car accident victim, and otherwise abides by the No-Fault Regulations, only to have his or her claim denied due to circumstances beyond his or her control.
We strongly advise our clients to educate their patients on the importance of responding to an insurance company’s reasonable EUO request.
Furthermore, to reduce the consequences of a patient’s failure to attend an EUO, we provide our clients with medical lien agreements. A medical lien allows a medical provider to seek direct payment from his or her patient (and/or from the settlement of the patient’s personal injury lawsuit) when a patient’s no-fault benefits are cut off due to a policy violation.
Upon the intake process at our clients’ offices, patients will be required to sign a medical lien. In that way, the patient acknowledges our client’s right to receive payment if the patient violates his or her no-fault policy.