Last Friday night the Florida legislature passed new standards as it pertains to Chapter 627 of the Florida Statutes. As expected these changes have created a sentiment of uneasiness among Florida PIP policy holders and medical providers. This uneasiness has been augmented by interpretations of the new standards by media. In many cases these interpretations are wrong or incomplete. This is to be expected as statutory interpretation (especially done under the deadlines imposed on journalists) is for the most part a complex matter. Furthermore, interpretations by the media tend to be oversimplified. Thus, our goal here is to provide an in depth analysis of the new 2012 PIP standards. To that end, we include here a link to the Florida PIP reforms passed on Friday, March 9, 2012.
Being South Florida car accident attorneys we have dealt with the issue of PIP on numerous other blogs. In those blogs we explained that PIP stands for personal injury protection. PIP is an insurance coverage that covers up to $10,000 of medical costs due to a car accident regardless of fault. For the most part, this still remains true. As Miami PIP attorneys we understand that this is a very important issue to medical providers and thus will address it first.
An insurance company must provide $10,000 in medical and disability benefits and $5,000 in death benefits resulting from injury as a result of ownership of a motor vehicle. The $5000 in death benefits are in addition to the medical and disability benefits provided under the insurance policy. The insurance company must provide coverage for 80% of all reasonable medical expenses as long as the individual receives initial services and care within fourteen (14) days after motor vehicle accident. Initial services can be provided by a medical doctor, dentist, chiropractic physician, or hospital, or hospital owned facility.
Reimbursements for services by the above is limited to up $10,000 if a physician, dentist, physician assistant, or advanced registered nurse practitioner, has determined that the injured person had an emergency medical condition. What should be noted here is that chiropractors are not on this list. This means that chiropractic physicians will not be eligible to bill up to $10,000 for medical emergency conditions. If a medical doctor, chiropractic physician, physician assistant, or advanced nurse practitioner, determines that the accident did not result in an emergency medical condition, then reimbursements are limited to $2,500.
This begs the question of what is an emergency medical condition. According to the new standard an emergency medical condition means, “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 definition is vague to say the least. Insurance companies will probably disagree with physicians as to what constitutes an emergency medical condition. This may lead to litigation in order to define the term. Ultimately, it may end up being a question for a jury to determine. However, it should be noted that the best person to make this determination is the examining physician. The physician who examines the injury closest in time to the accident will be best suited to determine whether it amounts to an emergency medical condition. It will be difficult to undermine these initial evaluations as they are related to the observations of the physician in that particular instance.
PIP medical benefits will not be extended to massage therapy or acupuncture regardless of whether an emergency medical condition is involved. It should be noted that an insurance company does not have to amend any policies in order for any of these changes to become effective. They are also not required to notify providers, or claimants, of such changes. The above mentioned changes will take effect on January 1, 2013.
Another area that will be affected by changes to the PIP statute is examinations under oath (“EUO”). An EUO Is a post loss requirement that may be a precondition to receiving PIP coverage. During an EUO the insurance company may ask an insured questions that are relevant to the loss. The new standard states; “the scope of questioning during an examination under oath is limited to relevant information or information that could reasonably be expected to lead to relevant information. Compliance with this…is a condition precedent to receiving benefits.” However, the insurance company must have a reasonable basis to take an EUO. Thus, they don’t have a carte blanche as it pertains to taking an EOU. Nonetheless, it should be noted that “[a]n insured’s refusal to submit to or failure to appear at two (2) examinations raises a rebuttable presumption that the insured’s refusal or failure was unreasonable.” In other words, if an insured fails to show up to two EUOs he must be able to show good cause for doing so.
The above covers most of import issues addressed in the new pip legislation. However, there are other points that should be covered that address questions regulating medical providers. These will be addressed with more specificity in another blog.
If you are medical provider or a PIP policy holder Fort Lauderdale accident lawyers are here to assist you. We are available 24/7 and can be reached at 305.764.9907 or 1.888.413.8353.