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%). Florida does not require any of us to purchase 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.
We are constantly asked by clients why their insurance company must pay their medical expenses when the other party was clearly at fault. The answer is simple: Florida law requires it. Thus, carrying adequate PIP and MP coverage is in your best interest.
How PIP Works and the Importance of the 14-Day Rule
Following an auto accident, PIP requires you to receive initial medical care, within 14 days, from an EMT or paramedic, physician (MD or DO), dentist, chiropractor, hospital, or hospital-owned facility. For the first 30 days after an accident, $5000 of your PIP benefits are reserved to pay for emergency medical treatment. Any funds not used for that purpose will be available for your other medical providers. If you are referred from a provider described above and your treatment is consistent with the underlying medical diagnosis rendered, you can obtain follow-up care. When you visit your doctor or medical provider, you should advise them you are there because of an auto accident and provide them your PIP information, including the name of your insurance company and the claim number. Follow-up care will be reimbursed up to $10,000 only if the finding of “emergency medical condition” is made. PIP reimbursement is limited to $2500 unless there is a finding that you have an “emergency medical condition” and must be made by a physician (MD or DO), dentist, physician’s assistant (PA), or nurse practitioner (ARNP). This finding cannot be made by a chiropractor. When a medical provider submits your bills directly to your insurance carrier, they will generally be paid 80%, up to $10,000. PIP does not pay for massage therapy or acupuncture.
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 you are released by your doctor, or your treatment is terminated by your insurance company following a compulsory medical examination (CME). The settlement of your Bodily Injury Liability claim at the end of your case does not affect your ability to receive treatment using your PIP. They are completely unrelated.
What is an Independent Medical Examination?
Florida law gives your insurance company the right to try and terminate your right to continued treatment under your PIP coverage. They do this by having you submit to a Compulsory Medical Examination (CME). This is an examination by a doctor of their choice, hired by them, for the specific job of challenging whether your continued medical treatment is “reasonable and necessary.” Many of these examinations appear to be anything but “independent,” and often result in reports finding the patient’s symptoms to be resolving and that further treatment is “not reasonable or necessary.”
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.
How Much Does PIP Pay for Lost Wages?
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. It is important to ask him/her to provide you a written prescription or off-work slip stating the dates you are to be out of work. If the doctor renews or extends an off- work period, obtain that in writing as well. These off-work orders must be provided to your no-fault/PIP carrier in order to obtain reimbursement for your lost wages. It is vitally important that you provide these off-work forms to our office as well. They will become an important part of your damage claim. Many doctors prepare only one copy of these off-work orders and give the original to you. Once you give them away, they are often hard to reproduce. Many doctors fail to include in their office notes specific times they ordered their patient off work.
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.
You must submit the completed wage verification form to your insurance company for processing under your PIP coverage. We can assist you in getting this done timely. It generally requires your employer’s cooperation. The insurance company must begin providing the PIP wages within 30 days of submission of the completed wage loss application, Wage and Salary Verification and doctor 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 financial (economic damages) claim, together with your pain and suffering (non-economic damages) claim.
Are Special Services Reimbursed?
If your doctor orders any special services to be provided during your treatment, ask him/her to provide a prescription for such services. This would include, for example, housekeeping services, yard maintenance or pool services. Again, while these are subject to reimbursement under your no-fault/PIP benefits, any payments will reduce the amount available to pay your medical treatment.
Be Proactive & Be Aware of Your Medical Costs
Every medical 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 doctor.
Bear in mind, you have a limited amount of PIP benefits. Those benefits will pay medical treatment and lost wages. However, when your insurance company has paid out the limits of your PIP policy, whether for wages or medical bills, their obligation to you is completed.
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 insurance company reserve a portion of your PIP benefits to pay your wage loss before paying medical bills. However, a 2008 amendment to the Florida Motor Vehicle No-Fault Law requires your insurance company to reserve $5,000 for medical expenses upon notification of a claim. Therefore, medical expenses submitted by medical providers up to $5,000 will 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.
The PIP statute requires reimbursement of all transportation costs incurred in connection with medical treatment that is reasonable and medically necessary.
You should record your mileage for travel to and from any accident-related medical provider. A mileage log can then be submitted to the insurance company for reimbursement of your actual mileage expenses.
Bear in mind that your PIP benefits are used to pay covered medical expenses, lost wages and mileage expenses for reasonably necessary medical treatment. However, when the benefits are exhausted, no further payments will be made. You may want to consider whether you want to defer reimbursement for mileage in order to maximize your medical or wage loss reimbursement.
Health Insurance / Medicare
If PIP benefits did not apply because you didn’t receive initial medical treatment within 14 days of the accident or if you have a need for extensive medical treatment or a prolonged wage loss, and you exhaust your PIP benefits, you may transfer your care to your health insurance company or to Medicare, if available. You must then comply with any Medicare or health insurance plan requirements. You have no obligation to repay Florida PIP benefits when you settle your case. That is not so with health insurance or Medicare, should you be required to use them for your accident-related treatment. When you settle your case, your health insurance company or Medicare will seek reimbursement for all accident-related benefits they provided for your care. This is referred to as having a right of subrogation. Health insurance companies and Medicare have a right of subrogation. PIP carriers in Florida do not. Reimbursement rights differ from plan to plan. We will fully explain how those reimbursement rights will affect your settlement.
Medical Payments / Subrogation
As indicated above, you are not required to repay your insurance company for PIP benefits. However, the law does entitle your insurance company to be reimbursed for Medical Payments benefits paid on your behalf. When your case settles, your auto insurance company may assert their right of subrogation (seek reimbursement) for those Medical Payments benefits. At the time your case settles, we will attempt to negotiate with your insurance company for a reduction or waiver of any reimbursement request.
Medical Treatment After Settlement
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 uninsured/underinsured motorist policy does not terminate your right to continued treatment. However, barring a compulsory medical examination termination, discussed above, 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.