Call Now For A FREE Consultation

(727) 451-6900

Get a Free Consult

Emergency Medical Condition: an Arbitrary Standard

01.22.2014 by | Insurance

No other provision in the current PIP statute, that went into effect on January 1, 2013, has created more litigation than the ambiguous emergency medical condition clause.  Ironically, resulting in the very problem the Florida legislature, in their wisdom, sought to eliminate; PIP litigation.

To-recap, the relevant provisions of the No-Fault statute state as follows:

“3. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. up to $10,000 if a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464 has determined that the injured person had an emergency medical condition.
4. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. is limited to $2,500 if a provider listed in subparagraph 1. or  subparagraph 2. determines that the injured person did not have an emergency medical condition.”

What remains unequivocally clear is that PIP benefits are limited to $2,500.00, if the insurance company determines, through an IME or peer review, that the insured did not sustain an emergency medical condition.  What remains unclear is when nothing is said either way:  there is no determination that the insured had an EMC and also no determination that the insured did not have an EMC.  It is in that gray area that PIP litigation has exploded.  Also presenting litigious issues are the form of the EMC, what language is needed, how soon must it be done, is an EMC a records request under Fla. Stat. 627.736(6)(b), does an emergency room visit count, how much support is needed, and other similar questions.

First, medical providers should be aware that at Dolman Law Group, we gladly prepare pre-suit demands for EMC cases, regardless of whether or not there has been an EMC determination. Second, assuming the insurance company has already limited benefits to $2,500.00, in compliance with the above-quoted paragraph, we will still pursue the case on grounds that the “non-EMC” determination was without basis or foundation; much the same way IMEs are fought. Finally, the golden ticket EMC cases are those were you have two conflicting opinions: that of a treating physician who determined the patient/insured had an EMC versus that of a physician records reviewer who came to a contrary conclusion. We eagerly seek and fight these cases until settlement is reached.

Medical providers, there is NO TIME LIMIT on when an EMC determination must be made! The infamous 14-day rule has NO bearing on EMCs; as it only involves initial medical care. Emergency room visits are proving to be another hotly contested area. Logic dictates that if an injured person presents to an emergency room following a car accident, they did so because their symptoms and complaints were severe enough, or caused such concern that treatment was urgent. However, insurers are taking the position that an EMC still has not been determined. But where in the statute does it prescribe the manner in which an EMC must be made? It doesn’t! Emergency room physicians are not going to present detailed office notes to the satisfactory of an ambiguous statutory provision. The fact remains, insurers will refute the presence of an EMC even when a medical provider, who is treating the patient, determines an EMC exists. Therefore, we are left with even more PIP litigation then before the EMC provisions were added. Ironic how the legislators sought to curb litigation and insurance fraud by adding the EMC provisions, only to have it result in a tidal wave of new claims.

If you are a medical provider, anywhere in the State of Florida, and your PIP benefits have been limited to $2,500.00 due to the emergency medical condition provisions in the No-Fault statute, we are willing and eager to help. We have represented numerous providers in countless claims involving EMC. Please call us if you have any questions or concerns on navigating the EMC provision and how we can help.

Dolman Law Group is proud to represent medical providers and independent MRI facilities across Tampa Bay, including but not limited to the counties of Pinellas, Hillsborough, Pasco, Manatee, Sarasota, Hernando, Citrus, Polk, and Charlotte. We are able to represent any provider across the State.

http://www.dolmanlaw.com/pip-personal-injury-protection-attorney/