Personal Injury Protection's 14-Day Rule and Emergency Medical Condition
In the 2012 Florida Legislative session, the Personal Injury Protection (PIP) statute was extensively amended (under House Bill 119); the laws officially went into effect in 2013. Although this may seem like old news, the time that has passed since the law came into effect has still not been enough for everyone to fully understand the new laws and how they affect them.There are two points that I often find clients need clarification on—or didn't know about at all: the 14-day rule and the Emergency Medical Condition rule. These laws determine how long you have to contact your insurance company to receive benefits for your injuries and what constitutes an emergency medical condition you can receive benefits for. Without knowledge of these two laws, you may be in the dark about the process of collecting benefits associated with your car accident.
What is Personal Injury Protection?Personal injury protection is a type of auto insurance that covers economic damages caused by a car accident. Florida's PIP statute governs the auto insurance that all drivers are required to carry. The idea is to get every injured person without having to fight over who is at fault. This is why the coverage is sometimes referred to as nsurance. Florida PIP gives all involved drivers insurance coverage which entitles them to have 80 percent of their medical expenses paid, up to $10,000. The following are some of the damages PIP covers:
- Medical bills
- Surgical services
- Rehab costs
- Death benefits
- Funeral costs
- Burial costs
- 60% of lost wages
What is the PIP 14-Day Rule?
One of the new provisions that majorly impacts thousands of Floridians is the 14-day rule or provision. Before the amendment, the Florida did not exist; there was no limit to the amount of time you had to seek treatment. Florida Statute 627.736 states that a motorist must seek medical care within 14 days after a motor vehicle accident from a hospital facility, emergency transport, medical doctor, doctor of osteopathy, chiropractor, or a dentist.
Medical Treatment and the 14-Day Rule
If one does not seek medical treatment within 14 days, they have forfeited their PIP coverage. This means that if certain symptoms do not surface within the two-week period, they will not be covered.
The new law dramatically limits the number of people that insurance companies must cover, which is exactly what they want. Failure to meet the new requirement will ensure that the innocent driver has to pay out of pocket if they don't have private health insurance.
14-Day PIP Rule Effects
Insurance companies don't have to cover as many people because of these new provisions, which increases their profits. According to the Florida Office of Insurance Regulation, the justification for the change is to decrease PIP fraud. According to them, personal injury protection fraud was a $600 million problem in the state of Florida. The hope was that if PIP fraud went down, premiums will go down.The 14-day rule helps with this by assuming that those who are really injured will seek medical attention right away. Those who find out about all the benefits they're missing later may make something up. Of course, this is not always the case, as most PIP claims are from perfectly honest and legitimately injured victims who need medical treatment and financial relief.
The change in the law was supposed to drive down premiums, but there have been questions as to whether that actually happened. I think most would agree they haven't. Some articles claim that premiums have gone down by as much as 15%.
PIP Emergency Medical Condition (EMC)
The amended Florida PIP Statutes 627.732 and 627.736 has left many physicians in the dark as to what truly constitutes such a condition. The amendment does expressly define an emergency medical condition (EMC) as a medical condition that manifests itself by acute symptoms of sufficient severity, which may include severe pain. The absence of immediate medical attention could reasonably be expected to result in any of the following:
- Serious jeopardy to patient health
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
However, as you can tell, there is plenty of room for interpretation, and clarity is not one of the law's virtues. Some victims of car accident injuries may not know if their medical condition can qualify as an emergency and whether their medical treatment is covered by PIP insurance. This can cause them to not get treatment and have their injury worsen or get treatment for an injury not considered an emergency and have to pay the expenses out of pocket.
The amended Florida "no-fault" statute went into effect on January 1, 2014, and expressly states that an EMC finding must take place for the claimant (injured person) to have access to the full $10,000 mentioned earlier. If a physician determines that a claimant's injuries do not meet the level of an EMC, then they are only entitled to just $2500 in PIP benefits for their medical treatment, which represents a 75 percent drop in benefits.
PIP Emergency Medical Condition Rule Controversy
What makes the provision so controversial is that it does not make clear exactly how a medical professional is supposed to decide that an injured person has an EMC. The statute does not outline specific guidelines for determining the severity of a medical condition outside of serious jeopardy to the victim's life. Some injuries fall in the gray area between catastrophic consequences and minor damages.Likewise, it is unclear how a medical professional should record an EMC. Should they specifically write "This patient's injuries qualify as an emergency medical condition" on their chart? If the diagnosis fits the above definition, is that good enough? Which doctor is in charge of making this assessment? The EMTs on the scene? The first medical professional you see at the hospital? The doctor you see the next day in their office? The provision has served to complicate the process for patients and medical professionals.
Denied PIP Payment as the Claimant
At Dolman Law Group, we regularly come across claims in which a Florida physician has been denied payment because the claimant's medical bills have exceeded $2500. Similarly, doctors are not paid because one of the earlier treating physicians did not expressly use the term "emergency medical condition" in their notes.
In fact, in many of our claims, the official records supplied to us by the medical provider(s) paint a clear picture that the patient has suffered an injury that clearly meets the definition of an EMC. However, the insurance carriers consistently ignore that part of the records. This behavior from the insurance company can leave them liable for a legal case regarding the wrongful rejection of PIP benefits to a deserving party.
How Insurance Companies Use PIP Rules to Deny Claims
Insurance carriers are beginning to utilize this new ability to deny car accident claims. Lately, we have noticed that the only claims being paid above $2500 are those that show the treating physician expressly used the term emergency medical condition. Florida auto insurance companies have uniformly adopted this self-serving interpretation of the amended PIP statute by adhering to a shift of burden that the statute fails to make mention of.
PIP claims adjusters are refusing to reimburse payments once the $2500 threshold has been met if the records are absent an expressed statement from a licensed physician that the patient has sustained an EMC. However, Florida's PIP Statute does not state a physician must find or make a determination of an EMC. Instead, the statute only provides clear guidance on what takes place if a physician determines that an EMC does or doesn't exist. Who or how the claim is made, it does not say.
Interpretation of the 14-Day PIP Rule
Statutory construction requires a strict interpretation of an existing statute. In order for a judge to side with an insurance carrier on this issue, there must be a record of the treating physician determining the patient had an EMC, and their medical report must expressly state the term "emergency medical condition."
The claims adjuster handling the case is not required to exercise a duty of due diligence in their investigation of the claim and the medical records provided. In other words, they have no obligation to interpret the findings of a medical doctor who did not expressly use the phrase but whose description of the injury clearly fits within the guidelines.
However, in accordance with Florida Administrative Code, the adjuster must diligently investigate the claim. The claims adjuster may be interpreted as having to review the records and make a determination as to whether the claimant's symptoms are of such severity that, in the absence of immediate medical attention, their injury could reasonably be expected to result in serious jeopardy to their health, serious impairment to a bodily function, or serious dysfunction of a bodily organ or part.
What if There is No Emergency Medical Condition?
The amended Florida statute does not say what happens if there is no determination of an EMC. The statute spells out what takes place if there is a determination of an EMC (i.e., $10,000 in benefits) and what happens if there is no determination of an EMC (i.e., $2500 in benefits). The statute makes no mention or reference to any requirement that a physician must expressly state the term 'emergency medical condition' in their notes.
Although the amended statute may have a purpose, and it may have the good intentions of decreasing fraud and premiums, the reality is that thousands of people with real injuries and a real need for medical benefits are being denied coverage. The purpose of the PIP laws in the first place was to prevent real victims from being denied coverage on the grounds of technicalities and long, drawn-out battles of liability. However, these new amendments are creating new issues opposing the original law's good intentions.
How Can a Personal Injury Protection Lawyer Help You If Your PIP Claim is Denied?If you suffered an EMC but were denied PIP benefits, a PIP attorney can help you pursue compensation from the insurance company that rejected your claim for benefits. The lack of specificity in the PIP statutes makes it challenging to hold insurance companies accountable for their rejection of PIP benefits. However, your lawyer could make the case that you suffered an EMC despite not appearing in your medical report's language. Your PIP lawyer can collect evidence that speaks to the severity of the injury you suffered. Using your medicals and hospital records, they can make the case that your injury was severe based on the cost of medical treatment and your condition when you went to the hospital. They can also speak to expert witnesses that have knowledge of car accident injuries. Your personal injury lawyer can attest to whether your injury was severe enough to be considered an emergency medical condition based on their expert experience.
Contact Dolman Law Group for Help With Your PIP Claim
At Dolman Law Group, we have who battle insurance companies on a daily basis. We know how much more difficult it is to be reimbursed for damages as a result of an auto accident because of the changes made in 2012. 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 the personal injury protection attorneys at today for a free consultation. Our firm works on a contingency fee basis, so we will not collect any payment until we have earned our clients the compensation they deserve. Call us at (727) 451-6900 or leave a message on our online contact page.