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PIP: 14-Day Rule and the Emergency Medical Condition

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. And although this may seem like old news, three years has still not been enough for everyone to fully understand the new laws and how it affects them. There are two points that I often find clients need clarification on—or didn’t know about at all. They are the 14-day rule and the Emergency Medical Condition rule.

For more information on PIP check out this FAQ on PIP medical coverage and PIP in general.

PIP 14-Day Rule

Florida’s PIP statute governs the auto insurance that all drivers are required to carry. The idea is to get every injured person in an accident medical coverage without having to fight over who is at fault. This why the coverage is sometimes referred to as ‘Florida No-Fault Insurance’.

One of the new provisions has a major impact on thousands of Floridians: the 14-day rule or provision.

Because of Florida PIP, all drivers have insurance coverage which entitles them to have 80 percent of their medical expenses paid, up to $10,000. It also covers other things like lost wages and death benefits. For more about these topics, see the linked articles.

Before the recent amendment, the 14-day provision did not exist; there was no limit to the amount of time you had to seek treatment. Now, the statute states that a motorist has 14 days after an automobile accident to seek medical treatment from either a hospital facility, emergency transport, medical doctor, doctor of osteopathy, chiropractor, or a dentist.

If one does not seek medical treatment within the 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 amount of people that insurance companies must cover; this is just the way they want it. Failure to meet the new requirement will almost surely ensure that the innocent driver has to pay out of pocket if they don’t have private health insurance.

Because of these new provisions, insurance companies don’t have to cover as many people, increasing 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/is a $600 million problem in the state of Florida. The hope was that if PIP fraud went down, premiums will go down. The way the 14-day rule helps with this is 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. In fact, most PIP claims are from perfectly honest, legitimate victims who are injured and need medical treatment and financial relief.

As to whether the change has caused premiums to go down? I think most would agree they haven’tIt should be noted however that some articles claim that premiums have gone down by as much as 15%.

PIP Emergency Medical Condition (EMC)

The amended PIP Statute found under 627.736 and 627.732, 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: 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:

  • 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 laws virtues.

The amended Florida “No-Fault” Statute went into effect on January 1, 2014, and expressly states that a finding of an EMC must take place in order 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. That’s a 75 percent drop in benefits.

What makes the provision so controversial, is that the statute does not make clear exactly how a medical professional is supposed to decide that an injured person has an EMC. Likewise, it is not clear how a medical professional is supposed to record an EMC. Should they specifically write “This patient’s injuries qualify as an emergency medical condition” on their chart? Or, 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? Who?

Denied PIP Payment as the Claimant

At Sibley Dolman Gipe Accident Injury Lawyers, PA, 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) paints a clear picture that the patient has suffered an injury which clearly meets the definition of an EMC. But the insurance carriers consistently ignore that part of the records.

In fact, insurance carriers are beginning to utilize this new ability to deny claims. Lately, we have noticed that the only claims that are being paid above $2500 are those that show the treating physician expressly using the three magical words: 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.

Note, however, that 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 exists.

How or who is to make the claim, it does not say.

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 finding on the record that an EMC was determined by the treating physician,
  • and, the term “Emergency Medical Condition” must be expressly stated within the language of the medical report.

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.

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. So this may be interpreted as: the claims adjuster must 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 EMC?

To recap, the amended 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 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; or to prevent long, drawn out battles of liability. However, these new amendments are creating their new issues that are opposing the good intents of the original law.

Contact an Experienced Florida PIP Attorney

At Sibley Dolman Gipe Accident Injury Lawyers, PA, we have an experienced team of PIP attorneys who battle insurance companies on a daily basis. Because of the changes made in 2012, it is now more difficult than ever to be reimbursed for damages as a result of an auto accident. 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 our personal injury protection attorneys at Sibley Dolman Gipe Accident Injury Lawyers, PA today at 727-451-6900 for a free consultation. Our firm works on a contingency fee basis, so we will not collect any payment until we have earned our client the compensation they deserve.