What Injuries Qualify as “Emergency Medical Condition” under Florida PIP Law?

When hospitals, doctors and medical staff need to decide whether someone’s car accident injury qualifies as an Emergency Medical Condition (EMC), what criteria do they follow? What types of injuries are they looking for?

Florida PIP Statute §627.732 states it this way:

An “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 would reasonably be expected to result in any of the following:

  1. Serious jeopardy to patient health
  2. Serious impairment of bodily function
  3. Serious dysfunction of any bodily organ or part

That is the extent of the statute definition of EMC. There is no list of injuries that meet these conditions, only a guideline by which qualified medical personnel can identify when an EMC event takes place.

Therefore, knowing what type of injuries or medical trauma will be classified as an Emergency Medical Condition (EMC) is at best imprecise and open to the interpretation of medical professionals and the court.

Speak with an experienced Florida attorney at our firm today.
Call 855-Kramer-Now (855-572-6376)
.

Who Is Qualified to Determine if You Have an EMC?

The medical provider making this call must be a qualified physician, osteopathic physician, dentist, physician’s assistant, or advanced registered nurse practitioner.

Emergency Medical Condition or Not: How Much PIP Coverage Do I Get?

A separate statute, Fla. Stat. §627.736 provides two basic scenarios about EMC coverage under PIP:

  • Reimbursement for medical care and treatment is awarded up to $10,000 if a qualified medical provider has determined that the injured person had an emergency medical condition. Any EMC coverage must be specifically related to the diagnosed conditions.
  • Reimbursement for medical care and treatment is limited to $2,500 if a provider determines that the injured person did not have an emergency medical condition.

Is There an EMC Form the Doctor Fills Out?

No, there is no form for medical personnel to complete. There is no specific language required under current law. This is another grey area of PIP law that our attorneys can guide you through.

In essence: to receive the full insurance award of $10,000, your medical record must establish that an Emergency Medical Condition is present.

As car accident attorneys who work with PIP insurance cases daily, our counsel may involve advising doctors how to clearly prepare this statement to avoid any doubt by the courts and possible resistance by insurance adjusters.

When Must an EMC Decision Be Made?

PIP law requires that someone injured in a Florida car accident must be seen by a qualified medical practitioner within 14 days following the accident.

Being treated medically within this time enables the injured person to receive PIP coverage of at least the minimum $2500 coverage.

Florida PIP law does not specify when an emergency medical condition should be established; therefore, an EMC does not have to be declared within these 14 days.

This is largely because medical evaluations such as imaging tests (MRI) and other diagnostic procedures and can take longer than 14 days. These tests are often the basis for concluding that the individual sustained an EMC.

Speak with an experienced Florida attorney at our firm today.
Call 855-Kramer-Now (855-572-6376)
.

Interesting Court Case Argues the Meaning of EMC

What happens if you had a medical evaluation within the 14 days after an accident, and there is no EMC determination by the medical practitioner? No mention at all of EMC?

In 2014, the U.S. District Court for the Southern District of Florida ruled in a case about this very thing. The case involved two parties’ different perceptions of the EMC provision.(1)

The plaintiff sued the insurer for breach of contract because the insurer did not pay her full Florida PIP benefits of $10,000.

The plaintiff’s interpretation of the law was that a person is limited to $2,500 only if the physician states that there is no emergency medical condition. In the plaintiff’s case, the physician never made a determination about her medical condition one way or the other. Even though the plaintiff did not have an EMC, she argued that she should still be entitled to the full benefit of $10,000.

The defendant, Progressive Select Insurance Company, interpreted the statute to mean that a qualified medical provider must declare affirmatively that yes, an emergency medical condition does exist in order for an injured person to be eligible for the full benefit of $10,000.

The court found in favor of the insurance company. The court also clearly affirmed that the intent of the EMC provision in Florida’s PIP statute is to reduce the occurrence of PIP insurance fraud by claimants.

This and other recent court decisions have set the stage that, in the court’s eyes, a medical provider must declare in their medical records that an EMC has been established. In other words, no confirming statement, no PIP benefits.

Confused about PIP and the EMC provision? Call us.

Various unanswered EMC questions remain for injury victims and those who must treat them. Insurance companies must also fit into the mix as they investigate claims.

In addition, PIP or no PIP, you may be eligible for vital compensation in a personal injury claim. The truth is, $10,000 of PIP can be wiped out before you ever leave the hospital.

To find out how an EMC and PIP coverage can affect your claim, contact Kramer Law. It important to call us so we can work to secure the maximum amount of benefits for you.


(1)
Sendy Enivert v. Progressive Select Insurance Co., Civil Action No. 14-CV-80279-Ryskamp/Hopkins (S.D. Fla. July 23, 2014)

Altamonte Springs Office
999 Douglas Avenue
Suite 3333
Altamonte Springs, FL 32714
407.834.4847
Downtown Orlando Office
37 N. Orange Avenue
Suite 500b
Orlando, FL 32801
407.339.0269
CALL 855-KRAMER-NOW