If an injured individual is found to have violated a no-fault policy based on either IME no-shows or EUO no-shows, what effect does that have on future claims, pending claims, and claims previously paid?
The breach of policy relieves the insurer of the obligation to provide coverage for all future claims for the injured party’s health services arising from the same accident. Pending claims submitted by the carrier may also be denied based on the policy breach.
However, if the pending claim is for treatment provided prior to the policy breach, an arbitrator or court of law may find the denial ineffective. An insurer’s successful denial of claims due to policy violation does not create a right of recovery for the insurer for benefits previously paid.