What Happens if You Were Injured and the Insurance Won’t Pay for It?

June 13, 2019 | Attorney, Matthew Dolman
What Happens if You Were Injured and the Insurance Won’t Pay for It? When Florida's no-fault insurance law was initially passed in the 1970s, the stated reason was to provide individuals with quick access to money to help with their recovery after being injured in a car accident, while at the same time alleviating the burden of personal injury lawsuits on Florida courts. However, many people who are injured in accidents find that their insurance carrier is reluctant to pay the full amount available to them for injuries, or refuses to pay any of their expenses at all. If you've been injured in a car accident and your insurance company won't pay, an experienced personal injury attorney may be able to help.

What Is PIP and What Is It Supposed to Cover?

At least $10,000 of Personal Injury Protection (PIP) coverage— also known as no-fault insurance—is required by state law for everyone registering a vehicle in Florida. The coverage is available to cover the medical expenses, lost wages, and death benefits of the insured, those living in the household of the insured, and those traveling in the insured's car who do not have a PIP policy of their own. Most of the time, your adult children, adult passengers, and adult friends who borrow your car will have a PIP policy of their own. PIP policies cover up to 80 percent of qualified medical expenses up to the limit of the policy, including:
  • Ambulatory costs
  • Medical services
  • Medications
  • Surgery costs
  • Hospital expenses
  • Diagnostic services
  • Rehabilitation services
PIP policies also cover up to 60 percent of lost wages, up to the policy limit, up to $5,000 for funeral and burial expenses, and reimbursement for mileage to and from your medical appointments. It is important to note that PIP coverage is limited to these items. Some of the things your no-fault insurance does not cover include:
  • Property damage to your car or any other vehicle involved in the accident
  • Bodily injuries to the occupants of the other vehicle
  • 20 percent of your first $10,000 worth of medical expenses for your emergency medical condition
  • 40 percent of your first $10,000 worth of lost wages due to missing work because of your injuries
  • Medical expenses or lost wages in excess of the policy limits
  • Pain and suffering and other non-economic claims
PIP insurance benefits are generally due within 30 days of being notified in writing of the covered loss and the cost of the loss. However, if the insurance company has reason to believe that your claim is fraudulent, it may take 60 days to investigate. There have been a number of efforts through the years by state lawmakers to repeal Florida's no-fault insurance system in favor of a system like most states have, in which vehicle owners would be required to purchase bodily injury liability coverage. As of yet, these efforts have not proven successful. However, the legal team at Dolman Law Group Accident Injury Lawyers, PA, and Dolman Law Group Accident Injury Lawyers, PA, is following the issue to make sure our team is up-to-speed on any changes to the law the moment they happen.

Why Would My Insurance Company Deny or Reduce My Claim?

While you may think your insurance company works for you, the truth is that insurance companies are in business to make money. One of the ways that they are able to do so is by avoiding paying out claims. There are a number of reasons why your insurance company might deny your PIP claim or may reduce the payout to you, including:
  • You were not found to have an emergent medical condition. Due to reforms to the PIP insurance laws that went into effect in 2013, those who are injured are only eligible to receive the full amount of compensation in accordance with their policy limits if they are found to have an emergency medical condition (EMC). An EMC is defined as a medical condition that is severe enough that the absence of immediate medical attention would place the patient in jeopardy of serious impairment to bodily functions or serious dysfunction to a body organ or part. Without an EMC, the claimant is only entitled to $2,500.
  • You didn't obtain your initial medical care within 14 days after the accident.
  • You did not file your claim within a timely manner.
  • Your initial services and care were not lawfully ordered, provided, and supervised by a licensed physician, dentist, or emergency transportation or treatment provider, or in a hospital or a facility owned by a hospital.
  • Your follow-up treatment was not provided through a referral from a licensed provider or was not consistent with the underlying medical diagnosis that was given when you initially received care.
  • You did not supply your insurance provider with a wage and salary verification form that showed what your earnings were in the 13 weeks before the accident, so they are unable to determine how much to compensate you for lost wages.
  • Your claim is found to be fraudulent.
  • It is discovered that your injuries were the result of a pre-existing condition.
  • You were found to have been driving under the influence at the time of the accident.
  • You are seeking coverage for treatments from a massage or acupuncture therapist. Massage and acupuncture are not covered by PIP policies.

Can I Sue My Insurance Company to Obtain the Compensation I Am Entitled to Receive?

If your insurance company has wrongfully denied your claim, you may be able to not only file a lawsuit seeking the compensation owed under the policy, but also to file a bad faith lawsuit against your insurer. However, after reviewing your policy and the written reason for your denial to ensure that you have a valid claim, your car accident attorney will likely attempt to achieve an alternative solution first. One of the alternative solutions may be to file an appeal with the insurance company, providing additional evidence to validate your claims. If the appeal of your claim is not successful, then consideration should be given as to whether your insurance company is acting in bad faith. Some examples of how an insurance company can act in bad faith include:
  • Failing to respond to the insured's claim with either an acceptance or denial
  • Refusing to give a reason for a claim denial
  • Insisting on an unreasonable amount of paperwork and documentation when evaluating a claim
  • Making a settlement offer that is much too low to cover the extent of the insured's injuries
  • Failing to pay for a valid claim
  • Attempting to change a policy after the claim has been made
  • Failing to provide an explanation along with payment of the claim as two which coverage the payments are under
When filing a bad faith lawsuit against the insurance company, your attorney must provide written notice to the state's department of insurance and the insurance company at least 60 days before the claim is filed with the court. This notice must include:
  • The facts and circumstances of the alleged bad faith violation
  • The names of all individuals involved
  • Reference to the specific policy language relevant to the violation
After receiving the notice of the intent to file a bad faith suit, the state department has 20 days to determine if the notice is complete. If it is not, then the 60 day period will not begin until all information required for the notice is complete. If the damages are paid or the issue causing the violation is rectified during the 60 days, the action cannot proceed.

Can I Make a Claim Against the Other Driver's Insurance?

Because of Florida's no-fault insurance laws, you are only eligible to file a claim against the other driver's insurance once you've reached your own PIP policy limits, you are able to prove that the accident was the fault of the other driver, and your injuries have been deemed serious. If a settlement is not forthcoming from the insurance company, then you may also be able to pursue a personal injury lawsuit for serious injuries. According to state law, a serious injury is defined as:
  • Significant and permanent loss of an important body function
  • Permanent injury within a reasonable degree of medical certainty
  • Significant and permanent scarring and disfigurement
  • Death
To pursue compensation from the other driver's insurance, you must first be able to prove that the driver's negligence led to the accident that caused your injury. If you were partially to blame for the accident, you may still be eligible for the recovery of damages. However, your award will be reduced by the percentage of blame that you bear. Some of the damages you may seek to recover through a third-party insurance claim or a personal injury lawsuit include:
  • Property damage
  • Medical expenses
  • Lost wages
  • Loss of future earning capacity
  • Cost of household chores that you are no longer able to do because of your injuries
  • Pain and suffering, emotional distress, loss of companionship, and other general damages
  • Punitive damages in cases where the other driver's negligence was particularly egregious

What Can I Do to Make My Case to My Insurance Company?

While you can't necessarily prevent an insurance company from acting in bad faith, there are some things you can do in order to strengthen your insurance claim, such as:
  • Seek medical treatment immediately, even if you don't “feel” injured. Many serious injuries have delayed symptoms. Seeking medical treatment immediately not only improves your chances of having your injuries diagnosed and treated as soon as possible, but also helps begin the process of your PIP claim. It should be noted that, in order to receive the full amount of your policy, you must have an emergency medical condition. However, that emergency medical condition doesn't have to be discovered or diagnosed during your initial treatment.
  • If possible, take photos of the accident scene. Also, obtain the contact information for anyone who witnessed the accident.
  • Obtain a copy of the police report from your accident.
  • Hire an experienced personal injury lawyer to help you understand your legal rights and provide guidance through the complex claims process.
  • Keep copies of all medical bills you receive, as well as information on your diagnoses and other written documentation of your injuries that can be used as evidence when making your claim.
  • Keep a journal of information regarding your accident, including records of your scheduled appointments and the impacts that your injuries have had on your daily life.
  • Do not give statements to representatives from the insurance company without first talking to your attorney.
  • Even if you feel like the accident was partially your fault, do not admit blame to the insurance company.
  • Do not accept a settlement offer without first speaking to your attorney. Often, quick settlement offers do not take into consideration the future needs of the claimant. Once you sign a settlement agreement, you will be unable to go back and ask for more money later.
  • Talk to a lawyer before agreeing to be evaluated by a doctor of the insurance company's choosing. Do note, however, that your policy will require you to cooperate with the insurance company, and that may include submitting to an evaluation by a doctor of the insurance company's choosing.

The Benefits of Hiring an Attorney to Help With Your Claim

Many injured accident victims file a claim with their insurance carrier on their own. Unfortunately, if the claim gets denied, they often try to go through the appeals process on their own as well. The problem, however, is that the process can be complex and they are up against an insurance company who has its own attorneys and a bottom line it is trying to protect. Hiring an attorney with experience in car accident cases and insurance claim denials puts someone in your corner who has the legal knowledge, extensive skill in negotiation, and the resources to help you get the maximum amount of compensation available to you. With offices across both Florida coasts, you can easily reach Dolman Law Group Accident Injury Lawyers, PA, and Dolman Law Group Accident Injury Lawyers, PA, at 833-552-7274 (833-55-CRASH), or contact us online to schedule your free consultation and case review. Dolman Law Group Accident Injury Lawyers, PA 800 North Belcher Road Clearwater, FL 33765 (727) 451-6900 https://www.dolmanlaw.com/florida-personal-injury-lawyer/


Matthew Dolman

Personal Injury Lawyer

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 successfully fought for more than 11,000 injured clients and acted as lead counsel in more than 1,000 lawsuits. Always on the cutting edge of personal injury law, Matt is actively engaged in complex legal matters, including Suboxone, AFFF, and Ozempic lawsuits.  Matt is a lifetime member of the Million Dollar Advocates Forum and Multi-Million Dollar Advocates Forum for resolving individual cases in excess of $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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