Personal Injury Protection's 14-Day Rule and Medical Emergencies
In the 2012 Florida Legislative Session, the Personal Injury Protection (PIP) statute was substantially amended (under House Bill 119); The laws officially went into effect in 2013.
While this may sound like old news, the amount of time that has passed since the law came into force is still not enough for everyone to fully understand the new laws and how they affect them.
There are two points that I often find clients need clarification on — or didn't know about at all: the 14-day rule and the emergency medical condition rule.
These laws determine how long you must be in contact with your insurance company to receive benefits for your injuries and what types of benefits you can receive for what constitutes a medical emergency.
Without knowledge of these two laws, you may be in the dark about the process for collecting benefits associated with your car accident.
What is Personal Injury Protection?
Personal injury protection is a type of auto insurance that covers economic losses caused by a car accident. Florida's PIP law regulates the auto insurance that all drivers are required to carry.
The idea is for each injured person to accident medical coverage without having to contend with who is at fault. This is why the coverage is sometimes referred to as Florida no-fault insurance.
The Florida PIP provides insurance coverage to all covered drivers that entitles them to pay 80 percent of their medical expenses up to $10,000. The following are some of the disadvantages covers:
Surgical services
Rehab costs
Funeral costs Funeral costs
Lost
PIP60% of wages
PIP insurance can cover up to $10,000 worth of damages associated with a car accident.
However, you will need to receive treatment within 14 days of the auto accident to receive the benefit.
For more information on the PIP 14-day rule and emergency medical conditions, PIP Medical Coverage and PIP in general. See FAQ.
What is the PIP 14-day rule?
One of the new provisions that majorly affects thousands of Floridians is the 14-day rule or provision.
Prior to the amendment, the Florida 14-day accident law did not exist; There was no limit to the amount of time you needed to undergo treatment. Florida Statute 627.736 states that a motorist must seek medical care from a hospital facility, emergency transportation, medical practitioner, doctor of osteopathy, chiropractor, or dentist within 14 days of the motor vehicle accident.
Medical treatment and the 14-day rule
If a person does not seek medical treatment within 14 days, they lose their PIP coverage.
This means that if certain symptoms do not occur within a period of two weeks, they will not be covered.
The new law dramatically limits the number of people insurance companies must cover, which is exactly what they want.
Failure to meet the new requirement will ensure that the innocent driver will have to pay out of pocket if they do not have private health insurance.
Effect of 14-day PIP Rule
Insurance companies do not have to cover more and more people due to these new provisions, which increases their profits.
According to the Florida Office of Insurance Regulation, the rationale for the change is to reduce PIP fraud.
According to him, personal injury protection fraud was a $600 million problem in the state of Florida. It was expected that if PIP frauds go down, premiums would also go down.
The 14-day rule helps with this by assuming that people who are actually injured seek medical attention.
People who come to know about all those advantages which they are lacking later on, they can make up for something.
Of course, this is not always the case, as most PIP claims are from completely honest and legitimately injured victims who are medical treatment and financial relief.
The change in law was expected to reduce premiums, but questions have been raised as to whether this actually happened.
I think most would agree they haven't. Some articles claim that the premiums have been reduced by up to 15%.
PIP Emergency Medical Condition (EMC)
Revised Florida PIP laws 627.732 and 627.736 have left many physicians in the dark as to what such a condition actually is.amendment clearly emergency medical condition (EMC) definesIn the absence of immediate medical attention, any of the following can be expected to result:
a serious hazard to the patient's health a
serious impairment of bodily functions
a serious dysfunction of any bodily organ or part
However, as you can tell, There is a lot of room for interpretation, and clarity is not one of the law's virtues.
Some victims injured in a car accident may not know whether their medical condition may qualify as an emergency and whether their medical The treatment is covered by PIP insurance.
This could result in them not getting treatment and getting worse or getting treatment for an injury that is not considered an emergency and having to pay out-of-pocket costs.
The amended Florida "no-fault" statute went into effect on January 1, 2014, and explicitly states that an EMC finding must occur in order for the claimant (injured person) to have access to the full $10,000 previously mentioned.
If a physician determines that the claimant's injuries do not meet the EMC level, they are entitled to only $2,500 in PIP benefits for their medical treatment, which represents a 75 percent drop in benefits.
PIP Emergency Medical Condition Rule Controversy
What makes the provision so controversial is that it does not clarify how a medical professional should determine that an injured person has EMC.
The statute does not outline specific guidelines for determining the severity of a medical condition beyond a serious threat to the life of the victim. Some injuries fall in the gray area between catastrophic results and minor damage.
Similarly, it is not clear how a medical professional should record EMC. Should they specifically write "this patient's injuries qualify as a medical emergency" on their charts? If the diagnosis fits the definition above, is that good enough?
Which doctor is in charge of making this assessment? EMT at the scene? The first medical professional you see in the hospital? The doctor you meet with in their office the next day? The provision has served to complicate the process for patients and medical professionals.
In Claimant Denied PIP Payment
, we regularly encounter claims in which payment has been denied to a Florida physician because the claimant's medical bills exceeded $2500.
Similarly, doctors are not paid because one of the first treating physicians did not explicitly use the term "medical emergency" in his notes.
In fact, in many of our claims, the official records provided to us by the medical provider(s) paint a clear picture that the patient suffered an injury that clearly meets the definition of EMC.
However, insurance carriers consistently ignore that part of the record. This behavior of the insurance company may make them liable to a legal case regarding wrongful denial of PIP benefits to an eligible party.
How Insurance Companies Use PIP Rules to Deny Claims
Insurance Carriers Car Accident Claims. Recently, we have noticed that only those claims that are paid over $2500 show that the treating physician has explicitly used the term emergency medical condition.
Florida auto insurers have adopted this self-serving interpretation of the amended PIP statute, similarly following a shift in the burden that the statute fails to address.
PIP claims adjusters are refusing to reimburse payments after the $2500 limit is met if records are absent of an express statement from a licensed physician that the patient has maintained EMC.
However, Florida's PIP statute does not state that a physician must detect or determine EMC.
Instead, the statute only provides clear guidance as to what happens if a physician determines whether an EMC is present. Who made the claim and how, it has not been told.
14-day PIP rule
The statutory construction requires a strict interpretation of the existing statute.
For a judge to side with an insurance carrier on this issue, the treating physician must have record that the patient had an EMC, and their medical report must clearly contain the words "emergency medical condition".
There is no requirement to exercise a duty of due diligence in medical records.
In other words, they are under no obligation to interpret the findings of a physician who did not explicitly use the phrase, but the description of the injury clearly fits within the guidelines.
However, according to the Florida Administrative Code, the adjuster must carefully investigate the claim.
The claim adjuster may be interpreted as reviewing the record and determining whether the claimant's symptoms are of such severity that, in the absence of immediate medical attention, their injury could be expected to seriously endanger their health.
Can , severe impairment of bodily function, or bodily organ severe dysfunction of a
FOR FREE LEGAL CONSULTATION 866-481-5503 WHAT
IF IT IS NOT A MEDICAL EMERGENCY?
The amended Florida statute does not say what happens if an EMC is not determined. The law describes what happens if an EMC (i.e., $10,000 in benefits) is determined and what happens if no EMC (i.e., $2,500 in benefits) is determined.
The statute makes no mention or reference to any requirement that a physician must clearly state the term 'emergency medical condition' in his or her notes.
While the amended statute may have a purpose, and may have fraud and reduce premiums, the reality is that thousands of people with genuine injuries and in genuine need of medical benefits are being denied coverage.
The purpose of the PIP laws was to prevent genuine victims from being denied coverage based on technicalities and long, drawn-out battles of liability in the first place. However, these new amendments are creating new issues contradicting the good intentions of the original law.
How Can A Personal Injury Protection Lawyer Help You If Your PIP Claim Is Denied?
If you faced EMC but were denied PIP benefits, a PIP lawyer can help you pursue compensation from the insurance company that rejected your claim for benefits.
The lack of specificity in PIP laws makes it challenging to hold insurance companies accountable for denying them PIP benefits.
However, your solicitor can make the case that you suffered EMC despite not being represented in the language of your medical report.
Your PIP lawyer can collect evidence that shows the seriousness of the injury.
Using your medical and hospital records, they can make a case that your injury was serious based on the cost of medical treatment and your condition when you went to the hospital.
have Expert witnesses knowledge of the injuries sustained in the car accident.
Your personal injury attorney can certify whether your injury was severe enough to be considered a medical emergency based on their expert experience.
Contact Dolman Law Group for help with your PIP claim At Dolman Law Group
we havean experienced team of PIP lawyers who fight with insurance companies on a daily basis. We know how difficult it is to get reimbursed for damages that result from an auto accident because of the changes made in 2012.
Florida's no-fault insurance was supposed to make things easier. Instead, insurance companies have taken advantage of recent changes in disputes and have rejected more and more claims.
If an insurance company has denied your PIP claim, schedule a personal injury protection attorneys free consultation with Our firm works on a contingency fee basis, so we will not take any payment until until we give our customers the compensation they deserve. Call (727) 451-6900 Leave a message Online Contact page.
Dolman Law Group Accident Injury Attorneys, PA
(727) 451-6900