Florida PIP or No-Fault Benefits Explained

August 19, 2016
Florida PIP or No-Fault Benefits Explained An automobile accident often damages more than just your car. Medical bills, lost wages, and other expenses can accumulate quickly and begin to apply serious financial pressure on you and your family. Personal injury protection can help cover those costs. It can even help protect your friends and family after an accident by covering them also. Personal Injury Protection—commonly referred to as PIP—is a supplemental form of insurance that strictly applies to injuries sustained in an automobile accident. It's also commonly called “No-Fault Insurance” because it is the most commonly required coverage in no-fault states. The PIP statute under Florida law can be found in Fla. Stat. 627.736. [1] What does “no-fault” mean? With standard auto liability insurance, the insurance company of the at-fault driver pays for the injuries and damages incurred by the other driver. With regard to car insurance, the term “fault" refers to who caused the accident. You are considered to be the at-fault driver if you are determined to be the primary cause of the accident. Fault isn't always clear-cut. One driver may be 60% at fault while the other driver is 40% at fault. [2] Florida's PIP insurance is a mandatory insurance policy that all registered vehicles must have. If you have a registered automobile in Florida, you must carry a minimum of $10,000 in PIP benefits. It is called no-fault car insurance because it is a type of insurance that will help pay for your own medical costs after a car accident, regardless of who was at fault for the accident. The beauty of Florida's PIP statute is that the insurance company cannot take “fault” into account when reviewing your submitted claims. Thus, Florida's PIP law is designed to provide swift and virtually automatic payment so that an injured driver can remedy their injuries, without having to fight with the insurance companies over who caused the accident. With liability auto insurance, you may end up waiting some time for your claims to be paid out if the insurance companies involved are arguing over who is at-fault. When it comes to medical issues, immediate treatment is paramount. What medical benefits does PIP cover?
  • Medical Benefits
Under a basic Florida PIP policy, insurance companies are required to reimburse 80 percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices and medically necessary ambulance, hospital, and nursing services. However, Florida's PIP statute includes several limitations on what services and care will be reimbursed. The insured party will only be reimbursed for initial services and care that was provided by:
  • a doctor, licensed under chapter 458 or chapter 459;
  • a dentist, licensed under chapter 466;
  • a chiropractor, licensed under chapter 460;
  • a hospital or a facility owned by a hospital;
  • EMS services
This basically means that the person providing the care must be licensed. This means to exclude non-licensed health services like acupuncture, herbalism, massage, naturopathy, traditional Chinese medicine, etc. Follow-up care that is related to the accident-caused diagnosis, must be provided by the same types of health professionals or certain other types that the patient was referred to by the above. See the statute for more details: 627.736 (1)(a)2.
  • Disability benefits
PIP covers reimbursement of up to 60 percent of any loss of gross income and loss of earning capacity, per individual, from inability to work proximately caused by the injury sustained by the injured person. In other words, if you have been injured in an auto accident and your injuries are preventing you from working, then you have an eligible claim for lost wages. Gross income mean any income that would have been earned by working during the time that someone was injured Earning capacity means someone's ability to earn in the future Also, any service for the benefit of the household that an injured person would have usually done themselves, but now has to pay someone else to do it, is also covered. For example, if a person can no longer clean their own house and now must hire an outside company to perform the service Disability benefits are to be paid at least every 2 weeks, as would be the standard for someone to receive a paycheck in a bi-weekly pay period.
  • Death Benefits
In the horrific event that a person dies from injuries sustained in an auto accident, PIP covers up to $5,000 of death benefits per individual. Death benefits are in addition to the medical and disability benefits. This is because, often, before someone dies, they incur medical costs. The $5,000 death benefit is paid like a life insurance-type policy in a lump-sum. These benefits are paid to the executor or administrator of the deceased; or to any of the deceased's relatives by blood, legal adoption, or marriage; or to any person appearing to the insurance company as equitably entitled to such benefits. Am I automatically qualified for $10,000 in benefits? The PIP statute was amended in the 2012 legislative session by Chapter 2012-197. The changes were drastic and extensive, completely changing how PIP operated. Prior to 2012, injured drivers were automatically eligible for $10,000 in benefits under their PIP policy. However, following this monumental reform to the PIP statute, Florida's no-fault law now requires documentation that the injured driver suffers from an “Emergency Medical Condition” (EMC) in order to be eligible for the full $10,000 in benefits. Without such documentation, you may be limited to only $2,500 in policy benefits for a “non-emergency medical condition.” What is an Emergency Medical Condition? Emergency medical condition is defined by Florida Statute 395.002(8)(a) and is as follows: A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
  • Serious jeopardy to patient health, including a pregnant woman or fetus;
  • Serious impairment to bodily functions, or;
  • Serious dysfunction of any bodily organ or part.
With respect to a pregnant woman:
  • That there is inadequate time to effect safe transfer to another hospital prior to delivery;
  • That a transfer may pose a threat to the health and safety of the patient or fetus; or
  • That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. [4]
This is a sweeping change and has created a challenge for injured drivers. Insurance companies are taking full advantage of this new rule and are cutting benefits off unless they have “proof” there is an EMC. Further, we have seen insurance companies dispute initial findings of an EMC by using what is called an Independent Medical Examination or peer review. This recent change has provided insurance companies with an extra tool to deny or delay insurance claims. What is the 14-day rule? Another very important provision that was amended in 2012 requires that injured drivers obtain medical treatment within 14 days of the accident. Similar to the EMC change, this requirement has allowed insurance companies to deny reimbursement of services merely because an injured person was not treated by a doctor or medical professional within the first 2 weeks. Policyholders should be well aware of this provision and seek treatment immediately. Unfortunately, this law fails to recognize that injured persons possess all different levels of pain tolerance—some being able to withstand more pain for longer periods of time than others. Similarly, injuries and symptoms often do not arise right away. Sometimes it takes days or even weeks for someone to notice an injury or its severity. This is why attorneys always recommend that you seek medical evaluation as soon as possible after an accident. You never know what is going on under the surface. Nonetheless, Florida drivers should understand if they neglect to be treated for their injuries within 14 days of the accident, they will not be reimbursed for any of their medical benefits. Who is covered under PIP? According to the statutes that outline PIP law, every policy is required coverage benefits for:
  • The named insured;
  • Relatives living in the insured's household;
  • Anyone driving the insured vehicle;
  • Passengers in the motor vehicle; and
  • Other persons struck by such motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle.
There are also a few things can exclude someone besides anything listed above:
  • If someone was operating the vehicle without permission;
  • If the claimant intentionally caused the injury;
  • If the claimant was injured while committing a felony.
Contact an experienced PIP attorney. At Dolman Law Group Accident Injury Lawyers, PA, we have an experienced team of PIP attorneys who battle insurance companies on a daily basis. Because of the changes made in 2012, it is now more difficult than ever to be reimbursed for damages as a result of an auto accident. Florida's No-Fault insurance was supposed to make things easier. Instead, insurance companies have taken advantage of the recent changes to dispute and deny more and more claims. If an insurance company has denied your PIP claim, contact our personal protection insurance attorneys at Dolman Law Group Accident Injury Lawyers, PA today at 727-451-6900 for a free consultation. Our firm works on a contingency basis, so we will not collect payment until we have earned our client the compensation they deserve. Dolman Law Group Accident Injury Lawyers, PA 800 North Belcher Road Clearwater, FL 33765 (727) 451-6900 References: [1] Stat. 627.736 [2] https://www.dmv.org/insurance/fault-and-no-fault-insurance.php [4] Stat. 395.002(8)(a) Referenced: Florida Automobile Insurance Law 9th ed. (Tallahassee, FL: Florida Bar, Continuing Legal Education, 2014): chapter 3: no-fault insurance.

Matthew Dolman

Clearwater Personal Injury and Insurance Attorney

This article was written and reviewed by Matthew Dolman. Matt has been a practicing civil trial, personal injury, products liability, and mass tort lawyer since 2004. He has represented over 11,000 injury victims and has served as lead counsel in over 1000 lawsuits. Matt is a lifetime member of the Million Dollar Advocates Forum and Multi-Million Dollar Advocates Forum for resolving individual cases in excess or $1 million and $2 million, respectively. He has also been selected by his colleagues as a Florida Superlawyer and as a member of Florida’s Legal Elite on multiple occasions. Further, Matt has been quoted in the media numerous times and is a sought-after speaker on a variety of legal issues and topics.

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