Insurance companies, such as Progressive, have recently been denying otherwise legitimate claims. Progressive, and others, have been consistently denying claims for (1) Manuel Therapy and (2) lack of an Emergency Medical Condition.
MANUAL THERAPY DENIALS
In 2012, the Florida Legislature reformed the PIP statute and made several sweeping changes. One of the most significant changes was excluding Massage Therapy from the list of reimbursable services. Under the revised statute, massage therapy (CPT 97124) cannot be paid for by your PIP policy. Progressive and other insurance companies, however, are denying Manuel Therapy services (CPT 97140) since this is a procedure that is routinely performed by massage therapists. Chiropractors, Physical therapists and some Physicians also perform Manual Therapy. This is just another example of insurance companies circumventing the law. They are denying these claims, alleging that they are not reimbursable under the PIP statute. Manuel Therapy and Massage Therapy are two separate, distinct services and charges, with the latter not being reimbursable. If your Manuel Therapy code has been denied, please contact the Dolman Law Group Accident Injury Lawyers, PA. We have been very successful in getting these services properly paid.
EMERGENCY MEDICAL CONDITION DENIALS
Progressive has been denying payment of claims in excess of $2,500 in PIP benefits by way of challenging an already determined Emergency Medical Condition. Under Florida’s no-fault law, a qualified physician under the statute must determine that the patient has an Emergency Medical Condition. Without such determination, the insured is limited to $2,500 in benefits.
What is an Emergency Medical Condition (EMC)?
In accordance with the applicable Florida PIP statutes (F.S. 627.730 – 627.7405), an EMC is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate attention would be reasonably expected to result in any of the following:
- Serious jeopardy to the patient’s health
- Serious impairment to bodily function
- Serious dysfunction of any bodily organ or part.
If a patient has had an EMC determination, they are eligible up to $10,000 in PIP benefits. If they do not have one, they are limited to $2,500 in benefits.
Who makes an Emergency Medical Condition Determination?
Only certain physicians can determine whether a patient has an Emergency Medical Condition. Pursuant to 627.726, only a (1) M.D. – Medical Doctor (2) D.O. – Doctor of Osteopathic (3) D.C. – Doctor of Chiropractic (4) a Dentist (5) a Hospital or (6) persons providing emergency transportation.
When do I have to obtain an EMC?
The most important timing issue that one must be aware of when it comes to PIP benefits is that an injured person must seek treatment within 14 days of the accident. Without documentation of being treated within those 14 days, the insured cannot be reimbursed for medical costs under their PIP policy. Further, although an EMC doesn’t necessarily have a timing requirement, the insured must understand that they need to get an EMC determination before the insurance company will reimburse in excess of $2,500.
Have you been limited to $2,500 in benefits, despite having a valid EMC determination?
As noted above, insurance companies like Progressive have been limiting benefits to $2,500, even if there has been an EMC determination. This is wrongful practice because the PIP statute does not expressly allow an EMC determination to be challenged. It is quite clear from the text of the statute that if you have had an EMC determined, then you are eligible for $10,000 in benefits, period. Insurance companies are attempting to circumvent the law by challenging EMC determinations, instead of merely paying out a legitimately valid claim submission.
Furthermore, Progressive is challenging an EMC determination by peer review of another qualified physician under the statute. In other words, if there has been an EMC determination, Progressive will hire their own doctor to review the records of the patient and say there is no EMC. Thus, without ever physically examining the patient themselves, the insurance company’s own doctor is contradicting another doctor’s opinion purely based on records alone.
CONTACT FLORIDA PIP SUIT ATTORNEYS DOLMAN LAW GROUP
We have been successful in challenging these types of denials. If an insurance company has denied your claim by attempting to challenge your EMC, contact our PIP attorneys at Dolman Law Group Accident Injury Lawyers, PA today at 727-451-6900 for a free consultation. 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