Emergency Medical Condition and Personal Injury Protection

Emergency Rooms often Don't Determine Emergency Medical Conditions

Generally speaking, Florida residents do not understand personal injury protection (“PIP”). Further, Emergency Medical Condition (“EMC”) requirements are one of the most misunderstood aspects of PIP. 

Legislators invented the term EMC. Medical schools don’t teach physicians EMCs. That invention is why so many do not understand EMC and how it affects PIP coverage.

When a Florida resident is injured in a car crash, their insurance policy’s PIP coverage is meant to pay their medical bills up to $10,000.00. However, PIP will only pay $2,500.00 if there is no EMC determination from a doctor. This requirement has tripped up many personal injury cases. 

When the Florida legislature first created the requirement, both attorneys and doctors failed to understand the requirement. This led to them failing to make an EMC determination a priority. Thus, many personal injury clients had unpaid bills that PIP refused to pay for. 

EMC doesn’t change a victim’s injuries. Instead it prevents or allows insurance companies to pay doctors. That is why it is vital that any attorney understands EMC to better serve their clients.

What is an Emergency Medical Condition (“EMC”)?

The Florida legislature defines an Emergency Medical Condition as:

“a medical condition manifesting itself by 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:

  1. Serious jeopardy to patient health.
  2. Serious impairment to bodily functions.
  3. Serious dysfunction of any bodily organ or part.”

Doctors will often determine whether an EMC is warranted in a particular case by asking whether emergency medical attention could reasonably be expected to prevent the outcomes described within the statute. However, the doctor treating the patient must state specifically that an EMC occurred. Without an explicit statement, insurance companies will deny PIP coverage above the initial $2,500.00.

The EMC requirement becomes tricky when doctors who do not typically work on personal injury victims write medical reports. Emergency room doctors do not discuss EMC in their medical notes. That is because medical schools do not teach doctors about EMCs. So the question is, who determines whether an EMC occurred?

Who can Determine Whether an Emergency Medical Condition Occurred?

The PIP statute authorizes certain types of doctors and nurses to render EMC opinions. In fact, the statute authorizes MDs, DOs, Dentists, Physician’s Assistants (PAs), and Nurse Practitioners (NPs) to determine that an EMC has occurred. The only major group of doctors specifically not authorized to make EMC determinations are chiropractors.

The legislature has never explicitly stated the reason for the exclusion. However, one can guess that the legislature was intending to hinder chiropractors’ abilities to render unlimited care in a personal injury case. Chiropractic offices treat many personal injury victims. 

Thus, the statute forces the chiropractor to obtain the EMC opinion from another physician, PA, or NP. While this is logical, the statute contains a provision which would appear to reveal the true intentions of the legislature. Florida law does allow chiropractors to determine if there is no EMC. This means chiropractors can limit PIP coverage available in a car accident case, but they cannot determine an EMC has occurred.

Certain insurance companies (like Progressive) attempted to use this provision to cut off benefits on a massive scale a few years ago. Progressive would take cases where a physician determined that an EMC had occurred and forward them to chiropractors for a review. 

These doctors would then typically determine that no EMC had occurred (despite a previous finding by an authorized physician) without ever examining the patient. Then, Progressive would use this finding as a means to cut off PIP coverage at $2,500.00. 

Attorneys filed thousands of lawsuits against Progressive as a result of these cutoffs. Ultimately, Progressive paid millions in legal fees due to this strategy, but they likely saved money on unpaid claims overall.

Know Your Rights and Insurance Coverage

Florida residents have lost billions of dollars by not understanding the coverage their auto insurance policy confers upon them following an accident. Florida residents must understand the coverages afforded to them by law.

If you, or someone you love, has been injured in a car accident and wish to discuss the available coverage and other aspects of a personal injury case, call Knapp Accident & Injury Law at (813) 568-3724 today.

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