Florida PIP Insurance
What is PIP?
PIP, short for Personal Injury Protection, is a type of no-fault insurance coverage that provides personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle, passengers in the motor vehicle, and other persons struck by the motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle, to a limit of $10,000.00 in medical and disability benefits and $5,000.00 in death benefits resulting from bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle. The limit of $10,000.00 is subject to various rules and regulations, but ultimately is paid out at eighty percent (80%) of all reasonable expenses for medically necessary medical, surgical, x-ray, dental, and rehabilitative services, including prosthetic devices and medically necessary ambulance, hospital and nursing services if the individual receives initial services and care within 14 days after the accident. What this means is that once a bill is received by the insurance company which is billed under PIP portion of the insurance policy, the insurance company will pay out up to 80% of all qualified bills up to a limit of $10,000.00 if the injured person sought treatment within the initial 14 days of an accident and suffered an EMC.
Under Florida’s PIP Statute, unless an individual is seen by a doctor within 14 days after the accident, then that individual is not entitled to PIP coverage. Florida PIP. Being seen by a doctor under Florida PIP Statue means that the initial care and services provided within the first 14 days after an accident were provided by an M.D., D.O., D.C., dentist, hospital, facility owned, or that is wholly owned, by a hospital, or emergency medical personnel. Initial services and care may also be provided by a person or entity licensed under part III of chapter 401 which provides emergency transportation and treatment. The initial care and services may also be supervised, ordered, or prescribed by the aforementioned. Basically, if you’re injured in an accident, you must seek initial care for that injury within 14 days of you waive your right to PIP benefits under your insurance. In addition, pursuant to the Statute, medical benefits do not include massage or acupuncture, regardless of the person, entity, or licensee providing massage or acupuncture, and a licensed massage therapist or licensed acupuncturist may not be reimbursed for medical benefits under PIP.
EMC – Emergency Medical Condition
Under Florida Statute 395.002(1)(8)(a)(b), an EMC (Emergency Medical Condition) is 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, including a pregnant woman or fetus.
- Serious impairment to bodily functions.
- Serious dysfunction of any bodily organ or part.
- With respect to a pregnant woman:
- That there is adequate time to effect safe transfer to another hospital prior to delivery;
- That a transfer may pose a threat to the health and safety of the patient or fetus; or
- With respect to a pregnant woman:
- That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.”
While there is no set time that an EMC must be established pursuant to the PIP Statute, the statute does explain the significance of the determination that the injured person had an emergency medical condition vs. the injured person did not have an emergency medical condition. Although an EMC does not need to be established within the first 14 days after an accident to trigger PIP coverage, initial care and services within the first 14-days establishes an individual’s right to at least $2,500.00 in PIP coverage available to them. Thus, once a person has treated within the first 14-days following an accident, we get to the next step of whether that individual suffered an EMC or emergency medical condition to determine what amount of PIP coverage is available to them.
EMC vs. No EMC
Florida’s PIP Statue section 627.736(3) states that an individual is entitled to reimbursement for services and care provided in initial care and services and follow up services (subject to those services being provided by an approved medical provider under the Statute) up to $10,000.00 if a licensed physician, a dentist, a licensed physician assistant, or a licensed advanced practice registered nurse has determined that the injured person suffered an emergency medical condition. On the contrary, reimbursement for initial care and services and follow up services is limited to $2,500.00 if the injured person is determined to not have suffered an emergency medical condition. Thus, although a person received treatment within the first 14 days after an accident, if that person is determined not to have suffered an EMC, then PIP insurance will only cover up to $2,500.00 of their medical bills.
The Defendant in a Personal Injury Lawsuit is entitled to receive a set-off for any collateral source that exists. A collateral source is technically any place where benefits are available to an injured party for medical expenses, i.e. health insurance, automobile accident insurance that provides health benefits or income disability coverage, social security payments, and contractual wage continuation plan provided by an employer, to name a few. Typically, free or low-cost secondary source benefits, such as Medicare and Medicaid are not protected under Florida’s collateral source rule. In other words, if no other collateral source existed and the Defendant failed to receive full PIP benefits of $10,000.00 due to a failure to seek initial care and services within the initial 14 days after an accident, the Defendant would be entitled to a set-off of $10,000.00 from an verdict awarded to the Plaintiff since these benefits were available to the Plaintiff albeit they did not receive them for their own failure to act.
Although Florida’s PIP Statute can be potentially confusing and difficult to understand, we are here to answer any questions you may have when it comes to your PIP Insurance Benefits. If you have been in automobile accident and suffered an injury, make sure to seek treatment within the first 14-days of the accident so you don’t lose your rights to have your medical bills reimbursed under PIP Benefits.