Insurance Policies Generally

ORS 742.524
Contents of personal injury protection benefits

  • deductibles

(1)

Personal injury protection benefits required by ORS 742.520 (Personal injury protection benefits for motor vehicle liability policies) 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 two years 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 are presumed to be reasonable and necessary unless the provider receives 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; 2015 c.5 §4]

Notes of Decisions

Language of this section and [former] ORS 743.800 indicates that legislature was aware of family exclusion provision and chose to regulate it only to limited extent. State Farm v. Baughman, 57 Or App 576, 646 P2d 1022 (1982)

Where plaintiff, insured by defendant insurer, was injured in automobile accident and incurred expenses for transportation to medical appointments necessary to treat injuries, defendant insurer is not required to cover those transportation expenses. Dowell v. Oregon Mutual Insurance Co., 268 Or App 672, 343 P3d 283 (2015), aff’d 361 Or 62, 388 P3d 1050 (2017)

Presumption that medical expenses in personal injury protection claims are “reasonable and necessary” under this section is not conclusive and may be rebutted. McBride v. State Farm Mutual Automobile Ins. Co., 282 Or App 675, 386 P3d 679 (2016), Sup Ct review denied

Where defendant insurer failed to send timely denial of personal injury protection claims as required by this section and ORS 742.528 because of insured’s repeated failure to attend required medical examination within 60-day post-claim period to determine whether medical expenses were “reasonable and necessary,” insurer had contractual right to compel medical examination and obligation to investigate insured’s personal injury protection claims, but still had obligation under this section and ORS 742.528 to issue timely denial based on information insurer had or could reasonably obtain or expenses were presumed reasonable and necessary. McBride v. State Farm Mutual Automobile Ins. Co., 282 Or App 675, 386 P3d 679 (2016), Sup Ct review denied

Fifty-two-week limit on payment of personal injury protection benefits under automobile insurance policy applies on per-policy basis, and injured passenger receiving 52 weeks of benefits under vehicle owner’s policy may receive up to 52 weeks of additional coverage under passenger’s own policy. Padilla v. State Farm Mutual Automobile Ins. Co., 314 Or App 300, 499 P3d 100 (2021), Sup Ct review denied

Source

Last accessed
Mar. 11, 2023

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