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Home > Why PIP Law Claims Get Denied

Why PIP Law Claims Get Denied

Florida’s PIP law was supposedly written to provide a quick and sure way for car accident injury victims to get medical care after a crash without having to file a lawsuit against the other driver and fight for compensation by proving the other driver was at fault. Over the years, the insurance industry lobby has gotten a hold of the PIP law several times and amended it in ways that make the law more friendly and favorable to the insurance companies at the expense of injury victims and the doctors who treat them under an assignment of benefits.

Now, insurance companies have many different ways they can turn down a PIP claim and get out of paying what they should. As PIP law attorneys working for doctors, Shuster Saben Estevez is here to level the playing field, make sure insurers play by the rules, and help see to it that doctors get reimbursed for the services they provide to Florida car accident victims.

Read on to learn some of the ways insurance companies have to deny PIP claims and what we can do about it. If you need help getting your PIP claim paid anywhere in the state of Florida, call Shuster Saben Estevez for help.

Reasons Insurers Deny PIP Claims in Florida

Below are just some of the main ways insurance companies have found to deny PIP claims.

Treatment was not medically necessary, reasonable or related to the accident. Florida PIP law requires medical benefits to the tune of eighty percent of “all reasonable expenses for medically necessary” medical services. Insurers can force patients to attend an Independent Medical Examination (IME), which is a meeting with a doctor picked by and paid by the insurance company for the purpose of challenging the treatment provided by the patient’s treating physician. Patients are required to attend IMEs and can lose benefits if they refuse to show up. When IME doctors challenge your treatment, we challenge the IME.

Amount is in excess of permitted amount. Insurers might turn down a claim they say exceeds the amount customarily charged for the service. How is this amount determined? Factors that can come into play include what amount is usually accepted by the provider, reimbursement levels in the community, state and federal medical fee schedules, and other relevant information. We’ll work to put together a case that proves your charges are allowable.

Missing information. Insurers turn down claims on the basis they don’t have enough information. They might request additional information first through a 627.726 (6) (b) request for a written report from the medical provider. These requests must be honored by the provider, and they can drag out the time frame insurance companies have to pay otherwise valid claims.

Service not covered. Florida PIP law defines what types of medical services can be reimbursed and what can’t. Some of these services are broadly defined, leaving the insurance companies plenty of wiggle room to argue whether a given treatment fits within the scope of the law or not. We have settled countless claims and counsel on over 150 published orders. We know the relevant statutes and case law on issues like these and others.

Patient not covered. PIP law covers a named insured and relatives who reside in the policyholder’s household. It covers them as drivers, passengers, bicyclists and pedestrians. If there is any chance for the insurer to argue the patient is not eligible for PIP benefits, expect them to try it. When they are wrong, we help them see the light.

Initial treatment was not sought within 14 days of the accident. This is a requirement written into the law to limit claims and protect insurers. What counts as “initial services and care” is quite broad, as we can prove when we need to.

Patient did not have an emergency medical condition (EMC). Without an EMC, PIP benefits are limited to $2,500.00, even though the insured carries a $10,000.00 policy as required by law. We know the definition of an EMC and who can make that determination under the law, as well as when and how it must be made. This requirement is a 2012 addition to the law meant to further benefit insurance companies and line their pockets; we can guide you toward getting the full reimbursement of your claim as applicable.

Get the Help You Need With Your Florida PIP Claim

For every challenge, there is a response. If your claim for reimbursement is being unreasonably delayed, denied or underpaid, call Shuster Saben Estevez at 877-511-7829 or at one of our many Florida law offices to explore your options and build your case with the help of seasoned, aggressive and successful Florida PIP law attorneys. We are here for you when you need us, ready to take on the insurance companies when they aren’t playing fair.

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