PIP

Personal Injury Protection (PIP)
Personal Injury Protection (PIP) coverage, also known as No-Fault Coverage, is one of two types of automobile insurance coverage that is mandatory in the State of Florida (the other mandatory coverage is property damage coverage). PIP coverage is used to pay your medical bills and lost wages following an accident regardless as to who is at fault for the accident (hence the term No-Fault coverage). Essentially what this means is that regardless as to who’s at fault for an accident, your own insurance company will pay your medical bills and lost wages up to the maximum coverage amount. Florida requires a minimum of $10,000 in PIP coverage, although many companies allow a person to buy additional PIP coverage beyond $10,000.
Generally, PIP coverage pays your medical bills at 80% and your lost wages at 60%. The other 20% of your medical bills and 40% of your lost wages not paid by PIP is something your attorney will attempt to collect from the at-fault driver’s insurance company, or in certain circumstances from your own insurance company under your uninsured motorist (UM) coverage in the event the at-fault driver did not have bodily injury/liability coverage.
Most people who have never been involved in an accident or never received medical treatment or lost wages as a result of an accident are surprised to hear that their own insurance company is the one responsible for paying their medical bills and lost wages. As a result, people sometimes question whether or not they want to proceed with medical treatment for fear that their insurance rates will increase. However, keep in mind that PIP coverage is mandatory coverage that is required in order to operate a motor vehicle in the State of Florida. Thus, if you are injured in an accident the law requires your insurance company to pay your bills since Florida is what is referred to as a NoFault State (a state that requires its drivers to maintain PIP or No-Fault coverage on their policies). As a result, your insurance company should pay your medical bills and lost wages without issue since you paid for this coverage and it is the law, right? Unfortunately, that’s not always the case.
Since PIP coverage is mandatory in the State of Florida, it is the primary source of insurance coverage for medical bills. What this means is that if you receive medical treatment as a result of an automobile accident, your doctor is required to bill your automobile insurance company first in order to receive payment. In the event you also have health insurance, your doctor may bill your health insurer as well, however, your health insurer will require your automobile insurance company to pay their 80% of the medical bill before health insurance benefits are paid.  It is very important that your medical bills are being paid under your PIP coverage as required by the terms and conditions of your policy and according to Florida law. Otherwise, it is possible for a situation to arise where no health insurance company and possibly not even the other driver’s insurance company will consider your outstanding medical bills unless and until the first 80% is paid by PIP coverage.
As mentioned above, all too often insurance companies fail to pay medical bills and lost wages under PIP coverage despite the hundreds or thousands of dollars you have paid in insurance premiums for your coverage and regardless of the intent of the PIP statute (law) (which is to provide swift payment of medical bills regardless as to who’s at fault for an accident). Again, insurance companies are “for profit” companies whose number one priority is to make money. Thus, the more they have to pay out for medical bills and lost wages, the less money they make. This is something to keep in mind as we move throughout not only our discussion of your PIP coverage but also in considering any first party coverage (meaning the coverage provided to you by your own insurance company – clearly the other driver’s insurance company is going to do everything they can to minimize their payment to you as well).
2013 Changes to Personal Injury Protection (PIP)
14 Days to Get Treatment Following an Accident
  • What this means is that if you do not go see a doctor for your injuries within the first 14 days following an accident, then you will not be entitled to have any of your medical bills paid by your PIP coverage.
  • Coverage Is Either $2,500 OR $10,000 – No Longer Automatic $10,000
    • – The amount of PIP coverage a person is entitled to has also changed. The law still requires that you buy $10,000 in PIP coverage from your insurance company. However, you are only entitled to the full $10,000 in coverage for your medical bills and lost wages if a medical doctor (not a chiropractor) determines that you had an “Emergency Medical Condition”. If a medical doctor determines that you do not have an “Emergency Medical Condition”, then you are only entitled to $2,500 in PIP coverage for your medical bills and lost wages.
  • “Emergency Medical Condition” 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:
    – Serious jeopardy to patient health.
    – Serious impairment to bodily functions.
    – Serious dysfunction of any bodily organ or part.

    At first glance this appears to be a tough standard to meet. However, keep in mind that the definition basically requires two things:

    1.) “Severe pain”, although the term “severe pain” is not defined and is something that most accident victims experience following an accident, which is why they seek medical treatment;

    and

    2.) “Medical attention” that without it could result in “serious jeopardy to patient health”. Keep in mind that the definition does not state that the “severe pain” must result in “serious injury to patient health”. It only says that the “severe pain” “could reasonably be expected to result in” “serious jeopardy to patient health”. Most injuries that occur from an accident have the potential to result in “serious jeopardy to patient health”. If that potential didn’t exist, then most people would not seek medical treatment.

    Who Can You Treat With Following an Accident?
    The new changes to the PIP statute still allow a person to treat with a chiropractor or medical doctor. Unfortunately, the new PIP statute no longer covers massage therapy or acupuncture. Furthermore, although a person is still allowed to treat with a chiropractor, as mentioned above a chiropractor cannot be the one to determine whether or not you sustained an “Emergency Medical Condition”. That must be done by either a medical doctor (M.D.) or an osteopathic doctor (D.O.). Thus, if you start your treatment with a chiropractor then you will also need to see a medical doctor or osteopathic doctor in order for them to determine whether or not you had an “Emergency Medical Condition”. Also, although you may go to the emergency room for your injuries following an accident this does not automatically mean that you had an “Emergency Medical Condition” thereby entitling you to $10,000 in PIP coverage as opposed to $2,500 in PIP coverage. The safest thing to do is to see a medical doctor or osteopathic doctor and allow that doctor to make a definitive determination as to whether or not you had an “Emergency Medical Condition”. If you start your treatment with a chiropractor, then your chiropractor will most likely refer you to a medical doctor or osteopathic doctor. If that does not happen shortly after beginning your treatment, then you should contact your attorney to discuss the need to see a medical doctor or osteopathic doctor. Tell Your Doctor About All of Your Symptoms At Your First Visit!
    Examination Under Oath (EUO)
    Another additional provision in the new PIP statute states that a person seeking PIP coverage must submit to an Examination Under Oath (EUO) if so requested by the insurance company
    Independent Medical Examination (IME)
    The IME is explained in detail above. However, there is a new provision that states if you fail to appear at two scheduled IMEs, then there is a rebuttable presumption that your failure to attend was “unreasonable”. This is significant because the law allows your insurance company to deny PIP coverage to you if you “unreasonably” fail to appear at a scheduled IME. Now the failure to appear at two scheduled IMEs is a “rebuttable presumption” meaning if you fail to appear at two scheduled IMEs that you can overcome the presumption that it was “unreasonable” provided you have a valid explanation for not attending. Again, if you receive a notice scheduling you for an IME, the best thing to do is contact your attorney about the IME in hopes of avoiding any missed appointments anyway.