Personal Injury ProtectionWhat is an “Emergency Medical Condition”?

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PIP Law – Emergency Medical Condition

An Emergency Medical Condition (EMC) 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 serious jeopardy to patient health, and/or serious impairment to bodily functions, and/or serious dysfunction of any bodily organ or part.”

Trying to determine what an actual “emergency medical condition” is can be tough. The definition above was never applied for a reimbursement aspect; instead it was so that hospitals knew when an emergency situation was present. The whole definition is very ambiguous and it can be open to interpretation. Due to the vague legislative drafting, this definition has been the basis for numerous health care providers being unpaid or underpaid by insurers who define an EMC in their favor by claiming one does not exist. The vagueness in the Florida personal injury protection (PIP) insurance statute may ultimately present itself as a sustainable Constitutional challenge.

To muck up the waters even more, per statute Florida State 627.736(a), a chiropractor is not on the list of people that can decide whether or not someone qualifies as having an EMC.  It is a peculiar aspect of the personal injury protection (PIP) insurance statute that even though chiropractors are among fellow authorized practitioners to provide follow-up care; they are still not authorized to determine whether an injured person suffered from an EMC, which would open up the door to the full $10,000 in PIP benefits.

It is not merely a coincidence that the legislature omitted chiropractors from making any sort of EMC determination. Chiropractors just so happen to make up the bulk of PIP suits, and knowing that, insurers wanted to limit their powers to pursue PIP claims as much as possible. This has forced chiropractors into a position where they have to refer the patient out to a doctor of medicine (MD), doctor of osteopathic medicine (DO), dentist, physician assistant or an advanced registered nurse practitioner to fulfill the insurer’s requirement for an EMC. However, the statute itself doesn’t require the patient to ever even meet with any of the listed people authorized to determine an EMC.

A lot of people have been talking about PIP benefits being capped to just $2,500 if an EMC is not affirmed, but despite all the chatter, a plain reading of the PIP statute actually never mentions that the default payment is $2,500 if there is no EMC. In fact, the PIP statute clearly states in the pertinent part: “Reimbursement for services and care… is limited to $2,500 if any provider…determines that the injured person did not have an emergency medical condition.” The rational interpretation of this is that unless and until a medical provider declares that the patient did NOT suffer from an EMC, reimbursement for all services and care will NOT be limited to $2,500, but instead will default to the full $10,000 in PIP benefits.

Please contact us with your questions or concerns on navigating the “emergency medical care” provision. You can reach us by calling (404) 797-9696 or by emailing us at ashamis@sflinjuryattorneys.com. Our PIP attorneys at Shamis & Gentile,P.A. look forward to assisting you!

 

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