Florida Appellate Court Decides Key Question Regarding Excess PIP Benefits

ambulance in lotIn the recent case of Medical Center of The Palm Beaches v. USAA Casualty Insurance Co., the Florida Fourth District Court of Appeal had a chance to consider whether a qualified medical provider must determine that an emergency medical condition was present for benefit payments to exceed $2,500 under Florida’s Personal Injury Protection (PIP) statute. More specifically, in order for an insured to receive more than $2,500 in payments, does the insurer need to conclude that an emergency medical condition is present?

The insured in this case suffered injuries in a car accident. The injuries required her to seek medical care at an urgent care facility. At the facility, she indicated she was experiencing pain in her cervical region and right shoulder. The treating physician referred her to a physical therapist. After obtaining treatment, the plaintiff submitted invoices to the insurer, but the insurer denied the claim for compensation. According to its analysis, Florida Statutes section 627.736(1)(a)(4) only required the insurer to pay a maximum of $2,500 under the policy. It sent a letter to the insured, asking her to provide a determination from the treating physician stating that the plaintiff was experiencing an emergency medical condition.

The plaintiff filed a lawsuit against the insurer, stating that it breached the insurance agreement when it failed to pay for the full scope of the plaintiff’s medical treatment. After filing suit, the plaintiff sent a note from her treating physician stating that she was experiencing an emergency medical condition. The insurer then paid the outstanding invoices until the policy limits were reached. It moved for summary judgment, which the lower court granted, concluding that the statute in question capped medical benefit payments at $2,500 unless the insured can prove that they received emergency medical treatment. The lower court also agreed with the insurer that it was correct in asking for documentation regarding the nature of the plaintiff’s injury, and it rejected the plaintiff’s argument that the insurer waived its right to assert certain defenses when it paid the additional benefits.

The trial court certified a question to the court of appeal. In an action seeking no-fault insurance benefits under PIP, can an insured only receive benefits in excess of $2,500 when a medical provider has determined that an emergency medical condition existed? The plaintiff also appealed the lower court’s ruling.

The Fourth Circuit Court of Appeal concluded that benefits in excess of $2,500 are only available to an insured when a treating physician provides a determination that an emergency medical condition exists. In the absence of such a determination, the insurer is not required to pay PIP benefits beyond $2,500.

If you have suffered injuries in a car accident or another personal injury incident, you may be entitled to a settlement or a judgment in your favor. Florida has a complex PIP statute designed to ensure that victims receive appropriate compensation for their injuries. Interpreting this statute and understanding how it may apply to you can be difficult. At Lusk, Drasites & Tolisano, we proudly assist victims throughout Southwest Florida, including in Naples, Fort Myers, and Cape Coral. We offer a free consultation, so call us now at 1-800-283-7442 or contact us online.

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