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Determination of Emergency Medical Condition Required for PIP Benefits Exceeding $2,500

Oct 3, 2016 in Case Law Updates by

In Medical Center of the Palm Beaches v. USAA Casualty Insurance Company, 41 Fla. L. Weekly D2018b (Fla. 4th DCA Aug. 31, 2016), the Fourth District Court of Appeal concluded that a determination of an emergency medical condition is required for benefits exceeding $2,500 under Florida’s PIP statute.

The statute explicitly states that reimbursement is $10,000 when a physician, dentist, physician assistant, or advanced nurse practitioner “has determined that the injured person had an emergency medical condition.” The statute further limits reimbursement to $2,500 when a medical provider listed in the statute “determines that the injured person did not have an emergency medical condition.” However, the statute does not state if reimbursement is limited to $2,500 when no such determination is made. Thus, while the statute addresses the situation in which an affirmative determination of emergency medical condition has been made, it does not address whether reimbursement can exceed $2,500 if the determination was not made.

The appellate court relied heavily on the United States Court of Appeals for the Eleventh Circuit’s opinion addressing the same question. Looking at the legislative history of the PIP statute, the Eleventh Circuit reasoned that the intent of the statute was to “reduce fraudulent claims by making the full $10,000 amount of benefits available only to those insureds who suffered severe injuries” as evidenced by a determination of “emergency medical condition.” Thus, the Eleventh Circuit concluded that a determination of “emergency medical condition” is required for PIP benefits in excess of $2,500. The Fourth District adopted the Eleventh Circuit’s reasoning, and held that an affirmative determination must be made.

The court further considered whether an insurance company has the right to receive a written report of the insured’s emergency condition before issuing payment in excess of $2,500. In Medical Center of Palm Beaches, the medical provider did not timely respond to the insurer’s (6)(b) request for a written medical report to determine whether the provider was entitled to payment exceeding $2,500. Instead, the provider waited until it had filed suit against the insurer to provide the requested report.

The pertinent part of the statute states that a qualifying medical provider “shall, if requested by the insurer against whom the claim has been made, furnish a written report of the…condition.” Based on the clear language in the statute the court found that the insurer’s demand for payment was premature as it did not submit the requested report. The court explained that such a report was important in the insurer’s evaluation of whether a determination of emergency medical condition had been made, and thus of whether the insurer was required submit payment in excess of $2,500. To date, no other District Court of Appeal has ruled on this issue, so the Fourth District’s opinion binds all Florida trial courts.

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