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The Emergency Medical Condition Requirement Under Florida PIP Law

PIP insurance reimburses medical providers for up to $10,000.00 in medical expenses, but due to a pro-insurance company amendment to the Florida PIP law in 2012, reimbursement is limited to only $2,500.00 unless a medical provider determines the patient had an emergency medical condition (EMC). Insurance companies were glad to get this restriction written into the law, and in the years since, they have exploited this language to their benefit and the detriment of health care professionals and their patients.

The attorneys at Shuster Saben Estevez are experts in the field when it comes to understanding Florida PIP law. If you are a doctor battling to collect from an insurance company based on the treatment you provided to your patient for injuries they suffered in a Florida car crash, our lawyers will go to bat for you and help you get the full amount of reimbursement you are due.

What Is an Emergency Medical Condition?

The first thing to understand about an “emergency medical condition” is that it is not a medical term; it is a legal term invented to make it harder to get the full amount of PIP coverage. The term is defined in the Florida PIP law statute as follows:

“Emergency medical condition” means 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:

(a) Serious jeopardy to patient health.
(b) Serious impairment to bodily functions.
(c) Serious dysfunction of any bodily organ or part.

As a doctor who wants to be reimbursed for the medical services you provide, it is wise to be familiar with this definition and to put this determination in writing whenever it applies to the patient you are treating.

Who Can Identify an EMC?

By law, the following health care professionals can determine that an injured person had an emergency medical condition:

  • A licensed physician (MD, DO)
  • A licensed physician assistant (PA)
  • A licensed dentist
  • A registered advanced practice registered nurse (APRN)

Some insurance companies might go beyond the law and accept EMC determinations from other health care providers as well.

The EMC Requirement Is Separate From the 14-Day Treatment Period

Because of the way the law is written, it can be confusing regarding when the determination of an emergency medical condition must be made. Florida PIP law requires the patient to receive treatment within 14 days of the accident, with coverage limited to $2,500.00 unless the patient had an emergency medical condition. These are two separate requirements. First, the patient must seek treatment within 14 days of the crash to be covered at all. If the patient doesn’t get treatment until more than 14 days after the accident, the patient does not have a valid PIP claim for any benefits.

Assuming the patient gets treatment in 14 days and has a valid PIP claim, the maximum amount of reimbursement for medical expenses is either $2,500.00 or $10,000.00, depending on whether the patient had an emergency medical condition. There is no requirement in the law that the EMC be determined during the initial visit or within 14 days of the accident. So long as the EMC is determined by a professional as described above, the treating physician should be entitled to reimbursement for up to $10,000.00 in services, regardless of when the EMC determination is made.

Get the Help You Need With Your Florida PIP Law Claim

The law surrounding EMCs and other provisions of Florida PIP law can be confusing, and don’t expect the insurance company to go out of their way to explain it to you. What you can expect is for them to delay, deny or underpay your claim either with no explanation or with complex legalistic language that you don’t have the time or expertise to sift through. Shuster Saben Estevez can cut through the confusion and help you understand what level of reimbursement you are entitled to.

If you are having trouble with your Florida PIP law claim, call Shuster Saben Estevez at any of our Florida office locations, or call 877-511-7829 from anywhere statewide. We are here and ready to help you get the maximum reimbursement under Florida PIP law.

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