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Emergency Medical Condition: What Happens When a Physician Fails to Make a Determination?

The amended Florida PIP Statute found under 627.736 and 627.732 (which expressly defines Emergency Medical Condition in Florida), has left many physicians in the dark as to what truly constitutes such a condition. Fla. Stat. 627.732 expressly defines an “Emergency medical condition” (hereinafter referred to as “EMC”) means 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:

(a) Serious jeopardy to patient health.
(b) Serious impairment to bodily functions.
(c) Serious dysfunction of any bodily organ or part.

Our amended Florida no-fault Statute (627.736) went into effect on January 1, 2014, and expressly states that a finding of an EMC must take place in order for the claimant to have access to their full $10,000.00 afforded pursuant to their PIP coverage. The Statute expressly states that if a physician determines that a claimant’s injuries do not meet the threshold of an EMC, only $2500.00 of PIP benefits will apply towards medical treatment. However, the PIP statute provides no guidance applicable to the situation in which a physician or the physicians who have rendered medical treatment fail to affirmatively list a medical condition manifesting itself by acute symptoms of sufficient severity, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the patient’s health, serious impairment to a bodily function or serious dysfunction of any bodily organ or part.

Denied Payment as the Claimant

We regularly come across claims wherein a Florida physician has been denied payment as the claimant has exceeded $2500.00 in medical bills and the treating physicians have not expressly used the term “Emergency Medical Condition” in their notes. In fact, in many of our claims; the objective records supplied by the medical provider(s) paints a clear picture that the patient/claimant has suffered an injury that clearly meets the threshold of an EMC. The insurance carriers have consistently ignored such records. In fact, the only claims we have noted the applicable carrier paying in excess of $2500.00 in no-fault benefits is when a treating physician expressly used the three magical words; emergency medical condition. Florida auto insurance carriers have uniformly adopted the 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 on bills once the $2500.00 threshold has been met absent an expressed statement from a licensed physician that the patient has sustained an EMC. Florida’s PIP Statute does not state a physician must find or make a determination of an EMC. Unfortunately for insurance carriers, the Statute only provides clear guidance on what takes place if a physician determines that an EMC exists or there is a lack thereof.

Statutory construction requires strict interpretation of an existing Statute. In order for a Judge to side with an insurance carrier on this issue requires a finding on the record that an EMC must be determined by the treating physician, the term “Emergency Medical Condition” must be expressly stated within the language of the medical report, and the handling Claims Adjuster is not required to exercise a duty of due diligence in their investigation of the claim and the medical records provided.

As previously stated, Florida Statute is silent as to what happens if there is no determination of an EMC. The statute clearly spells out what takes place if there is a determination of an EMC (i.e., $10,000.00 in benefits) and what happens if there is a determination there is NO EMC (i.e., $2500.00 in benefits). The Statute makes no mention or reference to a requirement that a physician must expressly state the term ‘emergency medical condition.’ In accordance with Florida Administrative Code, the adjuster must diligently investigate the claim. Further, the Claims Adjuster must review the records and make a determination as to whether then claimant’s symptoms are of such severity that in the absence of immediate medical attention, 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.

Dolman Law Group
800 North Belcher Road
Clearwater, FL 33765

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