What is Considered an Emergency Medical Condition Under the New Personal Injury Protection Coverage (PIP) laws in Florida

March 20, 2012
By Demian Goldstraj on March 20, 2012 11:56 AM |

Recently the Florida legislature passed standards regulating PIP coverage in the state of Florida. Many attorneys, policy holders, chiropractors, and medical doctors have been trying to make sense of these new standards. As Miami car accident attorneys we understand that new laws and standards produce anxiety and uncertainty. This is augmented due to the fact that all drivers in the State are affected by these changes.

One of the major causes of uncertainty relates to the term emergency medical condition. The new PIP standards define emergency medical condition in the following manner; "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 the patient health.(b) Serious impairment to bodily functions.(c) Serious dysfunction of any bodily organ or part." This standard seems to be taken from the Emergency Medical and Active Labor Act (EMTALA) which can be found at 42 U.S.C. 1395d.

EMTALA is meant to induce hospitals emergency rooms to treat individual who have emergencies regardless of whether they have benefits. If a hospital emergency room determines that an emergency medical condition exists, then it would be required to stabilize the patient. The important thing to note here is the standard provided by EMTALA is almost always applied in emergency room situations. Indeed, the Florida lower chamber's early drafts of the law stated that an emergency medical condition could only be diagnosed in a hospital. The language in an early version of HB119 stated, "[t]he medical diagnosis and the determination of an emergency medical condition shall be rendered in a hospital." This may be evidence showing that the Florida legislature has a different concept for the application of the definition of emergency medical condition for private practitioners and clinics.

The final version of the new PIP law states that, reimbursement can be "up to $10,000 if a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464 has determined that the injured person had an emergency medical condition." Reimbursement is limited to $2,500 if it is determined that an emergency medical condition is not present. The fact that an emergency medical condition diagnosis need not be made at a hospital says volumes about the intent of the legislature.

As mentioned before, most if not all statutory interpretation of the Emergency Medical Condition standards are applied to emergency room situations. An example of such a case is Correa v. Hospital San Francisco, 69 F.3d 1184 (Court of appeals, 1st Circuit 1995). In this case an elderly patient is taken to a hospital complaining of chest pain, but is ultimately ignored. This ultimately leads the patient to expire. The court determined that a hospital has a duty to provide an appropriate medical screening and if an emergency medical condition exists, then the hospital has a duty to stabilize the patient. In another case, the court stated that EMTALA was enacted "in the mid-1980s based on concerns that, due to economic constraints, hospitals either refusing to treat certain emergency room patients or transferring them to other institutions." Torretti v. Main Line Hospitals, Inc. 580. F3d 160 (Court of Appeals, 3rd Circuit 2009). The plaintiff in most of these cases is trying to show that the hospital or health care facility owed a duty of care which the institution failed to provide. In other words, much of this case law deals with negligence or question of malpractice rather than questions of coverage. Thus, much is of the case law out there may not be directly applicable to PIP coverage analysis.

Indeed, the major concern for readers of this blog is coverage and payment up to $10,000 for PIP benefits. For the insured to be provided adequate treatment it would be preferable that the standard for an emergency medical condition be lax. Otherwise, a Florida PIP policy holder would be limited to $2,500 in benefits. The Arizona Supreme Court addressed the issue of coverage in Scottsdale Healthcare, Inc. v. Arizona Health Care Cost Containment System, 75 P.3d 91 (2003). ). In this case there was no dispute as to the emergency medical condition. As the Court noted, "[t]he question is] whether...at the time [of the transfer of the patients] ...each still suffered from an 'emergency medical condition'..." The court goes on to say that the "statute requires that the medical condition manifest itself by 'an acute symptom (including severe pain).'" The court further explains, "[t]he statute mandates that AHCCS must cover services for treatment of that condition so long as absence of immediate treatment for that condition could reasonably result in" serious jeopardy, serious impairment, or serious dysfunction to patient health. It is helpful for healthcare providers that severe pain is considered an acute symptom by many courts analyzing the definition of emergency medical condition.

As PIP attorneys in Florida we understand that these changes are producing anxiety and concern among health care providers in the State. Other blogs will be dedicated to what constitutes an emergency medical condition. This is only a preliminary blog. Other blogs will address what constitutes an acute symptom and whether subsequent treatment due to an emergency medical condition can be reimbursed up to $10,000. Also, we will address the effect of this new PIP standard on chiropractors.

We want to note that this new standard will most likely create substantial litigation. Ultimately, it is likely that courts will determine that whether an emergency medical condition exists is matter of fact that should be decided by a jury. If this ends up being the case, then it will be beneficial to policy holders and providers. Extended litigation will make it economically restrictive for insurance companies to contest the issue.

If you are a health care provider, doctor, chiropractor, or dentist please do not hesitate to call us if you have any questions pertaining to the new PIP standards. Our Miami-Dade PIP attorneys are here to assist you. We can be reached at 305.764.9907 or 1.888.413.8353.