FLORIDA “NO-FAULT” 2013
Florida is a “no-fault” state. The no-fault concept requires each of us to self-insure for our own auto accident-related medical treatment. We do this through the purchase of Personal Injury Protection (PIP) and Medical Payments (MP) coverage as part of our auto insurance coverage. An unusual aspect of Florida insurance law is that the state required minimum coverage includes only Property Damage (to repair someone’s property when we are at fault) and PIP (to pay our own accident-related medical expenses at 80%). In general, Florida does not require the purchase of Bodily Injury Liability coverage, which is coverage that would pay for bodily injury to the other party when we are at fault. Therefore, when someone says they are “fully insured” in Florida, it does not necessarily mean they have anywhere near adequate coverage for themselves.
We are constantly asked by clients why their insurance company has to pay their medical expenses when the other party was clearly at fault. The answer is simple; Florida law requires it to be done that way. Thus, carrying adequate PIP and MP coverage is clearly in your best interest.
The minimum PIP required in Florida is $10,000.00. However, under the current law, a PIP deductible can be purchased, but cannot exceed $1,000.00.
How PIP Works
Following an auto accident, you must seek medical treatment within fourteen (14) days. Generally, for the initial visit PIP allows you to see any doctor of your choosing, unlike an HMO or managed care plan which may limit or dictate your choice. When you visit your treating doctor, you should advise them that you are there because of an auto
accident and provide them the information on your PIP policy. When your doctor submits your bills to PIP, they will be paid 80% of the “reasonable and customary” expenses related to your treatment. You will begin to accrue an unpaid balance of the 20% not covered by PIP. After the initial visit, a medical opinion must be rendered by a medical doctor, doctor of osteopathic medicine, dentist, physician’s assistant, or registered nurse practitioner that the accident related injuries constitute a need for immediate medical attention because of a “emergency medical condition” which is defined 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, or 3) serious dysfunction of any bodily organ or part. This determination cannot be made by a chiropractic physician as per the statutory requirements. If this medical opinion is not rendered within the fourteen days in accordance with the above-stated guidelines, than the insured will be limited to $2,500.00 in PIP benefits. However, if this requirement is properly met than the insured will be entitled to a maximum of $10,000.00 in PIP coverage benefits. If treatment is not sought within the initial fourteen days after the accident, than the insured will be precluded from obtaining any PIP benefits. Massage therapy and acupuncture treatment have been excluded from the PIP statute and thus they will not be covered treatment under the PIP coverage.
If you have MP coverage on your auto policy, it will pay the 20% as it is incurred. If you have no MP coverage, the 20% becomes part of your claim against the at-fault party’s
Bodily Injury Liability coverage and will be included in any final settlement with the insurance company. While waiting for your case to settle, your doctor may request that you sign a Letter of Protection (LOP). This is an assurance by you and your attorney that the unpaid expenses will be paid out of the settlement of your claim. Any request for a LOP by your doctor should be discussed with my office before you sign.
You may treat under PIP until your benefits are exhausted or are terminated by your insurance company following an independent medical examination (IME). The settlement of your Bodily Injury Liability claim at the conclusion of your case does not affect your ability to receive treatment using your PIP. They are completely unrelated. If you are notified of one of these examinations, you should discuss it with my office. We will help prepare you for the examination. In the event the IME recommends no further treatment, we will discuss whether you may transfer your treatment to another specialty or whether we will refer you to an attorney to sue your PIP carrier to challenge the IME and seek to continue your PIP benefits. Attorney fees you may incur in a PIP suit are paid by your insurance company when you win the claim.
Should your treating physician write an order or prescription taking you off work for any period of time after your accident, your PIP will pay you 60% of your average weekly wage. Your employer will be asked to prepare a Wage and Salary Verification form showing your gross wages for the 13 weeks preceding the accident. There are alternative ways to calculate your average weekly wage if the Wage and Salary Verification would not apply or not fairly represent average wages for you.
Your must submit the completed wage verification form to your PIP carrier. We can assist you in getting this done timely. It generally requires your employer’s cooperation. The PIP carrier must begin providing the PIP wages within 30 days of submission of the completed wage loss application, Wage and Salary Verification and physician off-work slips.
The 40% of your wages not covered by PIP becomes part of your damages claim against the at-fault party’s insurance company. Bear in mind, they will make one payment to you to settle your claim. The at-fault party’s insurance carrier will not pay wages or unpaid medical bills as they accrue, nor will they agree to cover your need for future medical care other than through a lump sum settlement. These items become part of your overall economic damages claim, together with your pain and suffering and non-economic damages.
When you purchased your auto insurance coverage, you selected your PIP limits, traditionally $10,000.00. Higher limits are available. Every bill you incur will reduce your benefits. For that reason, we encourage you to be proactive and to be aware of what you are being charged, the necessity of the treatment and its frequency. Call my office if you have any concerns about medical costs you are incurring. Request a print out of your charges on a regular basis, such as weekly or monthly. If you are not progressing in your treatment, discuss other options with your physician.
Bear in mind, you have a limited amount of PIP benefits. Those benefits will pay medical treatment and lost wages. When your PIP carrier has paid out the limits of your PIP policy, whether for wages or medical bills, their obligation to you is exhausted.
Reserving Your PIP Benefits for Wage Loss
Following an accident, your treating doctor may order you not to work because of your injuries. You may be restricted from work for an extended period of time. In such a case, you should discuss with me whether it would be in your best interest to request that your PIP insurer reserve your PIP benefits to pay your wage loss before paying medical bills. Otherwise, medical expenses submitted by medical providers could be paid first and diminish or eliminate the PIP funds otherwise available to pay for your lost wages. This could create a greater financial hardship to you. Be sure to notify my office at your earliest opportunity if it appears you may be out of work for an extended time. We will discuss how this option may affect the payment of your anticipated medical care.
You may continue to obtain treatment under your PIP, or health insurance plan/Medicare, after your case is settled. Settlement with the at-fault party or under your own un-insured/under-insured motorist policy does not terminate your right to continued treatment. Your right to continued treatment under PIP would be limited by the amount of benefits you chose (i.e. generally $10,000.00) and could be terminated following an Independent Medical Examination, as discussed above. However, barring an IME termination, you may treat under your PIP so long as you need treatment or until your benefits are exhausted. That is why monitoring your expenses is important so that your benefits are not used unwisely and prematurely.