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By: Wayne Hogan and Leslie Goller

Last October, we at Terrell Hogan alerted you to the changes to the Florida’s Personal Injury Protection “PIP” insurance law. Beginning January 1, 2013, mandatory PIP insurance of $10,000.00 began paying $7,500.00 LESS in Florida for most motor vehicle accident medical claims than it did in 2012.

PIP insurance benefits tradi­tionally pay up to 80% of your medical bills related to an injured person’s auto accident and 60% of your lost wages. But now we are beginning to see how insurance companies are inter­preting the law to deny claims.

The PIP law requires you to get medical care within 14 days of the day of your car accident — from a hospital facility, emergency transport, physician, osteopath, dentist, chiro­practor, physician’s assistant, or nurse practi­tioner –or lose PIP coverage for ANY medical benefits related to your auto accident. In effect, “Use it or Lose it.”

The PIP law also requires that you be diagnosed with an “Emergency Medical Condition.” That diagnosis must be made by a physician or a physician assistant licensed under Florida Statutes Chapter 458 or 459, a dentist under Chapter 466, or an advanced regis­tered nurse practi¬tioner under Chapter 363, or your PIP medical benefits are limited to a total of $2,500.00 (not the normal maximum of $10,000.00). (A CHIROPRACTOR’S OPINION STATING THAT IT IS AN EMERGENCY MEDICAL CONDITION IS NOT ACCEPTED).

Now, we see how insurance companies are inter­preting the “Emergency Medical Condition” requirement to deny coverage. Some insurance companies are telling their insureds that the actual words “Emergency Medical Condition” must appear in their medical records and if not, PIP medical benefits are limited to $2,500.00. Some insurance companies are stating that soft-tissue injuries are not an “Emergency Medical Condition.”

The insurers’ inter­pre­ta­tions of the PIP law do not follow the Section 627,732(16), Florida Statutes, defin­ition of “Emergency Medical Condition”:

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:

a) Serious jeopardy to patient;
b) Serious impairment to bodily function; or
c) Serious dysfunction of any bodily organ or part.”

Thus, according to the language of the statute itself, soft tissue injuries can certainly be an “Emergency Medical Condition.”

The new PIP law has not affected lost earnings and loss of household services benefits. There is still up to $10,000.00 in coverage whether or not there is an “Emergency Medical Condition” deter­mi­nation.

Denial of your contractual PIP benefits may create a cause of action for Insurance company bad faith. Know your rights and contact us if this happens to you.

Important Changes Coming in PIP Benefits