What is considered a medical emergency by Personal Injury Protection (PIP) insurers?

Florida’s “no-fault” personal injury insurance system for car accidents has many positives, but it can also be quite confusing. One major source of misunderstanding is when you are able to receive the full $10,000 benefit for the purposes of paying for your emergency medical care.

medical emergency requiring an ambulance

Unfortunately for car accident victims in Florida, their personal injury protection (PIP) insurance will only provide the maximum benefit when the nature of their injuries would be considered as a “medical emergency.” That phrasing is quite vague, however, making the severity of your condition open to interpretation. Worst of all, if your condition is not considered a medical emergency, then your benefits are capped at $2,500.

While the laws surrounding PIP sound strict, know that you may have legal options. By working with a Tampa car accident lawyer, you can determine what benefits may be available and whether a third-party liability personal injury claim could be the best strategy for your situation. Seek the maximum amount of compensation for all of your losses, potentially beyond the PIP limits, by speaking to an experienced Tampa car accident injury law firm in a free, no-obligation case evaluation.

$10,000 PIP Coverage Limit Only Available in Medical Emergencies

Every vehicle owner in the state of Florida is required to purchase a PIP policy in the amount of $10,000. This policy is supposed to pay for 80% of the costs of your medical care and other essential expenses after you have been injured in a car accident, up to the $10,000 limit.

What sets this policy apart from “fault” states is that the benefits are available to you automatically, regardless of who was at fault for the accident. There’s no need to legally prove who was at fault or to seek insurance coverage for your damages from an at-fault person’s policy. All you need to prove was that an accident occurred and that you are in need of medical care.

As mentioned above, though, there’s one important catch: the full amount of benefits is only available when your injuries are considered to be an emergency medical condition. If your injuries are not an emergency medical condition, then you only have a maximum of $2,500 in coverage available for all of your post-crash expenses.

What Is the Definition of an Emergency Medical Condition, According to Florida Law?

At one point, the state of Florida had no formal definition for an emergency medical condition or EMC. This ambiguity led to many situations where someone could be granted or denied the full PIP benefits seemingly at random, depending on who was providing care and where the care was provided.

The statutes governing how PIP worked were amended in 2011 to include a number of extra provisions. One important provision was that injured persons only had 14 days to seek medical care from the date of the accident (or, in some cases, the earliest date they should have reasonably known they were injured). Otherwise, they wouldn’t receive any benefits at all under the PIP system and had to instead pay out of pocket or rely on their personal health insurance policy.

Another important change was that legislators added a clearer definition of what constituted a medical emergency. Florida Statutes §627.732 defines it as follows:

“Emergency medical condition” means 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:

  • (a) Serious jeopardy to patient health.
  • (b) Serious impairment to bodily functions.
  • (c) Serious dysfunction of any bodily organ or part.

This definition provides some more-concrete guidelines but does not spell out what an EMC is, exactly. For example, one doctor might judge that a lack of care could have hypothetically caused “serious dysfunction of any bodily organ or part,” whereas another could predict that the patient would have been relatively fine.

Who Determines Whether I Have an Emergency Medical Condition?

As hinted at above, it is up to the provider to determine if your injuries constitute an EMC.

More specifically, §627.736 states that the following individuals are qualified to assess whether or not an injured person has an emergency medical condition when they sought care after their collision:

  • A licensed physician
  • A licensed dentist
  • A licensed physician’s assistant (PA)
  • An advanced practice registered nurse (APRN)

What Happens If a Provider Listed Above Determines I Don’t Have an Emergency Medical Condition?

Unfortunately, if you go to receive medical care after you have been in an accident, then you run the risk that only $2,500 of your expenses will be covered, at maximum. While that amount may seem high, the reality is that emergency medical services can easily cause you to be billed far more than that amount. If you stayed in the hospital or received any specialized care, then your expenses will be even higher.

While it is likely that any medical visit that results in a recommendation of surgery or an inpatient stay would constitute an EMC, it is still possible that you are left with substantial unpaid bills after maxing out your available PIP benefits. The good news is that you may be able to receive a second opinion or appeal the finding with the help of a Florida personal injury attorney.

You may also be able to pursue a third-party liability claim against any available insurance carried by a party who is potentially at fault. In other words, if using your PIP insurance would result in significant unpaid bills, it’s possible for you to file a claim against the driver who hit you to recoup the remaining amount. This option is only available when you have a qualifying “serious injury”, but it can be highly important to receive the care you need and avoid long-term financial consequences following your collision.

Talk to Experienced Personal Injury Lawyers in Tampa

Whether you are seeking PIP benefits or a third-party bodily injury liability (BIL) claim, having your own attorney can make the process easier and potentially result in more compensation for your post-accident losses.

Work with Darrigo & Diaz, Injury Attorneys, to help you determine the best path forward after your accident. We have been advising clients since 1999 and helping them seek all available benefits for their crash injury damages. You deserve the best chances at getting all the compensation you need, and we are prepared to guide you through your case every step of the way. Most importantly, your first consultation is always free, and we never charge you until we are able to recover money for your damages.

Find out more about your legal options and get answers to your questions during a free, no-obligation case review. Schedule your free appointment with a Florida car accident lawyer now when you call (813) 774-3341 or contact us online.


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