Florida PIP Law
In Florida, the primary coverage for drivers who are injured in an auto accident is through their own personal injury protection insurance. Also referred to as “no-fault” coverage, benefits are paid for each injured person for medical services without regard to who was at fault in causing the accident.
Upon initiation of treatment, most medical providers obtain an Assignment of Benefits (AOB) from their patients. This allows the doctor to stand in the shoes of the patient and file a claim for reimbursement directly with the insurer.
This process works fine…until it doesn’t. Insurance companies sometimes look for any reason they can to limit what they have to pay out. Insurers have been known to unreasonably delay claims with lengthy investigations and requests for documentation, to deny claims on an illegal or incorrect basis, or to pay less than the law requires. These actions could be taken in bad faith, or they could be the result of a misunderstanding of the facts or a misinterpretation of the applicable law. Whatever the reason, the result is that you, as a doctor, don’t get paid for the services you provided in treating your patient.
Our practice is focused on representing medical providers and helping them collect payment under an applicable PIP policy. Since 2004, Shuster Saben Estevez recovered millions of dollars for our clients in unpaid PIP claims. We would welcome the opportunity to help you too. Below is a brief description of Florida PIP law. If you need help getting reimbursed for services provided after an auto accident in Florida, call Shuster Saben Estevez to speak with one of our attorneys.
What PIP Insurance Does and How It Works
Every owner of a motor vehicle in Florida is required to carry $10,000.00 in PIP coverage. PIP benefits pay for 80% of the medical services received to treat injuries incurred in an auto accident, including ambulance transport, doctor visits, rehabilitation, and medication. PIP benefits also cover 60% of an accident victim’s lost wages that result from the covered accident. In the event of a fatal accident, PIP coverage includes $5,000 in death benefits that can be used to help with funeral costs and related expenses.
In order to have a viable PIP claim, injury victims must seek treatment within 14 days of the accident. Additionally, insurers have the ability to limit a claimant’s PIP coverage to $2,500.00 (instead of $10,000.00) if they request a finding of an emergency medical condition (“EMC”) as defined in the law and determined by an eligible medical provider. As a doctor treating the patient under an AOB, these dollar limits apply as well to the amount you can claim in reimbursement from the insurer.
PIP benefits are available to people who are hurt in a car accident as a driver, passenger, bicyclist, or pedestrian. In addition to the named insured, PIP benefits cover any relative who lives in the policyholder’s household. Notably, however, PIP coverage does not apply to people injured while riding on a motorcycle.
Florida PIP law also limits the types of providers who can claim reimbursement and the types of treatment that are covered. Generally speaking, PIP covers services provided by a licensed medical practitioner, such as a medical doctor, osteopathic doctor, chiropractor, or dentist. Reimbursable costs include, among others:
- Ambulance costs
- Hospital expenses
- Rehabilitation costs
- Diagnostic services
- Prescription services
So-called alternative or complementary therapies — acupuncture or massage therapy, for example — are explicitly excluded from PIP coverage in Florida, but they may be covered under the patient’s health insurance policy.
An EMC, according to Florida law, is a severe medical condition that, if not addressed immediately, will result in one of the following:
- Serious jeopardy to the patient’s health
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
A medical doctor, doctor of osteopathy, physician’s assistant (PA), advanced registered nurse practitioner (ARNP), or dentist — must document the EMC in order for the patient to be eligible for PIP benefits of up to $10,000.00. While as previously stated initial medical attention must occur within 14 days of the accident, there is no reason to conclude that an EMC diagnosis is subject to this same time restriction.
How Do PIP Claims Get Paid?
Doctors providing treatment under an AOB should submit a claim for reimbursement within 35 days of the date of service. From there, the insurance company has 30 days to pay the claim, subject to certain exceptions. After 30 days, the claim is considered overdue. At that point, we can step in and provide legal services to help get the claim fully paid and in a timely manner. The steps we take include the following:
Sending a Demand Letter – This letter informs the insurer of their duty under the law and demands they pay the claim, with interest, plus a ten percent penalty (up to $250) and costs incurred in sending the letter such as postage. Insurers will often pay to settle a claim based on a carefully worded demand letter to resolve the matter and avoid further liability.
Filing a Lawsuit – If necessary, we can file a lawsuit in county court and get a judgment ordering the company to pay. Even after a lawsuit has been filed, we can still settle the case without going to trial. The process of litigating a lawsuit often gives each side a better understanding of the issues in the case and helps lead to a settlement.
Whether we settle the case through a demand letter or lawsuit, our costs and fees are paid by the insurance company and never by the medical provider. You will keep the full amount of your claim as just reimbursement for the services you provided.
You Don’t Have to Know Florida PIP Law. We Do.
Having to go after the insurance company to get paid what you are owed is no fun, but it’s worth the effort. You can’t afford to treat patients and not get paid for the services you provide. As a doctor, you focus on practicing medicine while your billing department focuses on getting you paid. When claims get denied, underpaid, or unreasonably delayed, it’s time to bring in legal help to resolve the matter once and for all. That’s what we do at Shuster Saben Estevez. With offices conveniently throughout Florida, we help doctors statewide get their PIP claims fully paid, with interest. For help with a Florida PIP claim, call Shuster Saben Estevez at 877-511-7829 to speak with one of our dedicated and experienced Florida PIP lawyers.
