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


The Florida PIP statute as amended under sections 627.736 and 627.732 (which clearly defines an emergency medical condition in Florida) has left many physicians in the dark as to what such a condition actually is. Fla. state. 627.732 clearly defines an "emergency medical condition" (hereinafter referred to as "EMC") to mean a medical condition manifested 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 danger to the health of the patient.

(b) Severe 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 clearly states that an EMC must be discovered by the claimant to gain access to his full $10,000.00 per his PIP coverage. The statute clearly states that if a physician determines that the claimant's injuries do not meet the EMC limits, only the PIP benefit of $2500.00 will apply for medical treatment. However, the PIP statute does not provide any guidance for a situation in which a physician or physicians who provided medical treatment fail to positively 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 cause serious danger to the health of the patient, serious impairment of bodily function or serious dysfunction of any bodily organ or part.

Payment Denied as Claimant

We regularly receive claims in which payment has been denied to a Florida physician because the claimant paid over $2500.00 in medical bills and the treating physicians noted in their notes The term "emergency medical condition" has not been used explicitly. In fact, in many of our claims; Objective records provided by the medical provider(s) present a clear picture that the patient/claimant has suffered an injury that clearly meets the limits of the EMC. Insurance carriers have consistently neglected such records. In fact, the only claim that the applicable carrier pays no-fault benefits in excess of $2500.00 is when the treating physician has explicitly used three magic words; emergency medical condition. Florida auto insurance carriers have similarly adopted a self-service interpretation of the amended PIP statute, following a burden shift that the statute fails to address. PIP claims adjusters are refusing to reimburse bills once the $2500.00 threshold is reached, while there is no express statement from a licensed physician that the patient has maintained EMC. Florida's PIP statute does not state that a physician must detect or determine EMC. Unfortunately for insurance carriers, the statute only provides clear guidance as to what happens if a physician determines that an EMC is present or lacking.

The statutory construction requires a strict interpretation of the existing statute. For a judge to side with an insurance carrier on this issue requires a finding on the record that EMC must be determined by the treating physician, clarifying the term "emergency medical condition" within the language of the medical report. must be disclosed, and the claims adjuster is not required to perform a duty of due diligence in the claims investigation and medical records provided.

As previously stated, Florida statute is silent about what happens if an EMC is not determined. The statute clearly states what happens if EMC is determined (i.e., $10,000.00 in profit) and what happens if there is no EMC (i.e., $2500.00 in profit). There is no mention or reference in the statute to any requirement that a physician must explicitly state the term 'emergency medical condition'. According to the Florida Administrative Code, the adjuster must diligently investigate the claim. In addition, the claims adjuster must review the record and determine whether the claimant's symptoms are of such severity that, in the absence of immediate medical attention, could reasonably be expected to pose a serious threat to their health, result in serious bodily harm, can be expected. Serious dysfunction or loss of function of a bodily organ or part.

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