PIP Coverage for Emergency Medical Conditions: Is the Limit $10,000 or $2,500?

All Florida auto insurance policies must include Personal Injury Protection coverage. This is commonly referred to as “PIP” coverage. What is Personal Injury Protection and what are the coverage limits? The answers to these questions are primarily found in Florida Statute 627.736, but are not always easy to decipher.

What Is Personal Injury Protection And What Does It Pay?

Florida Statute 627.736 requires your auto insurance policy to provide personal injury coverage up to $10,000 for medical benefits and disability benefits, and another $5,000 for death benefits. For medical benefits, the coverage is to pay 80% of non-excluded reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services

These expenses include prosthetic devices and medically necessary ambulance, hospital, and nursing services. For disability benefits, the coverage is to pay 60% of any loss of gross income and loss of earning capacity per individual from an inability to work caused by the auto accident injury, plus all expenses reasonably incurred in having to pay someone else to such things as housework or yard work that the injured person would normally have done themselves.

When Does Pip Not Have To Pay The Full $10,000 In Medical/Disability Benefits?

To receive the maximum amount of $10,000 of medical/disability benefits under the Florida PIP statute emergency medical condition, there must be a determination an emergency medical condition resulting from the accident. Otherwise, the PIP statute limits the benefits to $2,500. Most auto accidents will either have clear proof of an emergency medical condition, resulting in coverage up to $10,000 or will have clear evidence there is no emergency medical condition, resulting in a cap of coverage at $2,500. But, what happens when there is no evidence either way? In Medical Center of the Palm Beaches vs. USAA Casualty Insurance Co. (No. 4D14-3580), the Fourth District Court of Appeal recently looked at what should happen when there has been no determination by medical doctors in the initial records of an “emergency medical condition” resulting from the auto accident.

For Example...

The injured driver, in this case, developed pain to her right shoulder and cervical region after a car accident. She went to a treating doctor to discuss this problem and was simply referred to a physical therapy practice for conservative treatment without there being an actual determination of the nature and extent of her injury. She went to physical therapy, and the therapy facility then submitted bills for this treatment to the PIP insurance carrier for the patient. The insurance company refused to pay, explaining that it had no evidence of an emergency medical condition and the injured woman had already met her $2,500 limit.

The physical therapist office sued the insurance company for breach of contract for not paying the bills and also sent a note from the injured person’s treating physician, who had subsequently and retroactively diagnosed her with an emergency medical condition. The trial court ruled in the insurance company’s favor on summary judgment, agreeing with the insurer that the limit is $2,500 in the absence of a determination of an emergency medical condition from the outset.

The physical therapist office appealed and argued that the statute only limits the payment to $2,500 when a statutorily authorized provider determines there is no emergency medical condition. In this case, the initial notes of the treating doctor were apparently silent on the issue and the facility’s position was that the default should be paid up to $10,000 in the absence of a negation.

The appellate court, with an interesting twist of logic, disagreed with the physical therapy office and denied payment beyond $2,500. In doing so, it looked at the wording of the statute which first limits the PIP benefit to $10,000 for an emergency medical condition. The statute then limits the benefit to $2,500 when there’s been affirmative proof there was no emergency medical condition.

The statute does not address the specific situation of no determination at all. Rather than reaching the decision that the insurance company could only rely on the $2,500 cap when affirmative proof exists that no emergency medical condition resulted from the accident, the court decided to let the insurance company off the hook by allowing the $2,500 cap when the records of treatment are silent on whether an emergent medical condition exists.

Was this truly the legislative intent of the statute? Or, should the court have looked at the totality of the evidence available to determine whether coverage should be for $2,500 vs. $10,000? The 4th DCA does not issue controlling decisions for North Florida, so this logic does not have to apply to cases in our area. If you’ve been injured in an auto accident, you rely on prompt payment of benefits by your insurance company.

Questions about the coverage that’s available to you under your policy can be answered by the personal injury attorneys at Syfrett, Dykes & Furr.

Contact our office today at (850) 795-4979 for a free and confidential consultation.


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