Delaware Claims Dispute & Statutory Guide
Delaware operates an At-Fault automobile insurance framework with mandatory Personal Injury Protection (PIP) under 21 Del. C. § 2118. Policies must carry minimum limits of $15,000 per person and $30,000 per accident. Medical reimbursement is subject to a statutory fee schedule benchmarked to the state workers' compensation fee schedule, and unpaid claims are subject to administrative arbitration administered by the Delaware Department of Insurance.
Statutory Framework & Jurisdiction
Add-On PIP (Mandatory PIP with Statutory Fee Schedule & DOI Arbitration)
Delaware combines a fault-based tort liability system with mandatory first-party PIP benefits. Every registered motor vehicle must carry PIP coverage for medical expenses and wage loss incurred within two years of an accident. Reimbursement for healthcare services is capped under 21 Del. C. § 2118(k), which incorporates the workers' compensation fee schedule. Medical billing disputes between healthcare providers and auto insurers are adjudicated through binding administrative arbitration before the Delaware Department of Insurance.
PIP / MedPay Coverage & Medical Fee Rules
mandatory P I P Limits
$15,000 for any one person and $30,000 for all persons injured in any one accident, covering reasonable medical, surgical, dental, hospital, and funeral expenses incurred within 2 years of the crash (21 Del. C. § 2118(a)(2))
loss Of Earnings
Includes compensation for net loss of earnings and reasonable cost of essential personal services for up to 2 years
balance Billing Prohibition
Under 21 Del. C. § 2118(k), a healthcare provider may not balance bill or collect from an insured any fee exceeding the statutory fee schedule cap
assignment Of Benefits
Healthcare providers holding an executed assignment of benefits have direct standing to pursue PIP claims and demand arbitration
Official Medical Fee Schedule & Reimbursement Standards
name
Delaware Automobile PIP Medical Fee Schedule (21 Del. C. § 2118(k))
rules
Reimbursement is capped at the rates established under the Delaware Workers' Compensation Health Care Advisory Committee (HCAC) fee schedule authorized pursuant to 19 Del. C. § 2322B. If a service is not listed on the HCAC fee schedule, reimbursement is capped at the 75th percentile of usual and customary charges.
cpt Basis
HCPCS/CPT codes matched to Delaware HCAC relative values and geozip conversion factors
Preauthorization & Decision Point Review
requirement
Preauthorization is not required by statute for acute emergency treatment. For elective procedures, specialized surgical care, or extensive diagnostic testing, insurers may require pre-service notification and review of clinical documentation.
independent Medical Examinations
Under 21 Del. C. § 2118(h), insurers may require an injured person to submit to a physical examination by an independent medical practitioner.
Administrative Appeals & Dispute Mechanism
doi Administrative Arbitration
Under 21 Del. C. § 2118(j) and Delaware Insurance Regulation 1401, disputes between medical providers (holding an assignment of benefits) and auto insurers regarding fee reductions, medical necessity, or denied claims are resolved through binding arbitration administered by the Delaware Department of Insurance (Auto Arbitration Unit).
thirty Day Prompt Pay
PIP benefits must be paid within 30 days after the insurer receives reasonable proof of claim and loss.
court Litigation
If an arbitration award is appealed on legal grounds, review proceeds to the Delaware Superior Court.
Critical Statutory & Dispute Deadlines
| Dispute Phase / Trigger Event | Statutory Timeline / Deadline |
|---|---|
| Accident Notice | Notice to insurer as soon as practicable following injury |
| Treatment Incurral Window | Medical expenses must be incurred within 2 years of crash date (21 Del. C. § 2118(a)(2)) |
| Carrier 30-Day Pay Window | 30 calendar days from receipt of proof of claim |
| DOI Arbitration Filing | Within 3 years of claim denial or payment reduction (10 Del. C. § 8106) |
| Statute of Limitations | 2 years for tort personal injury actions (10 Del. C. § 8119); 3 years for PIP contract/arbitration (10 Del. C. § 8106) |
Required Evidentiary Filing Checklist
- ✓Delaware PIP Claim Application (Form PIP-1)
- ✓Executed Assignment of Benefits (AOB) authorizing direct payment to provider
- ✓Itemized CMS-1500 or UB-04 billing form with CPT/HCPCS and ICD-10 diagnostic coding
- ✓Clinical chart notes, physical therapy logs, operative notes, and diagnostic scan reports
- ✓Explanation of Benefits (EOB) or written denial from the PIP insurer
- ✓Completed Delaware Department of Insurance Arbitration Petition (when filing arbitration)
Official Primary Sources & Legislative Authorities
Governing Regulatory Authorities
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