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Many hospitals find auto insurers limiting benefits under the applicable Personal Injury Protection (“PIP”) policy to $2,500 in benefits when the policy provides for a $10,000 PIP benefit limit even when there’s clear emergency treatment in an emergency room setting. The key to unlocking the $10,000 in PIP coverage (as opposed to a limit of $2,500) is for ER physicians to affirmatively note in the patient records if there’s an Emergency Medical Condition (“EMC”). Auto insurers are assuming the injury is not an EMC unless told otherwise by a qualified physician, PA, or ARNP.
The legislature defines an EMC 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 any of the following: (a) serious jeopardy to patient health, (b) serious impairment of bodily functions, or (c) serious dysfunction of any bodily organ or part.” Some courts have held that there are no “magic words” that denote an EMC and that a finding of a broken bone was sufficient to put the insurer on notice of the EMC and require the auto insurer to cover benefits up to $10,000. The key is: Could the patient’s medical condition reasonably be expected to be made permanently worse absent immediate medical intervention?
Even though a patient’s records may reflect they have a broken bone, or possibly even surgery as a result of the auto accident injuries, many auto insurers will still limit benefits to $2,500 unless the magic words “EMC” are in the medical records. The best practice would be for ER physicians to indicate in the patient’s records that they have determined this patient had an emergency medical condition when the patient’s condition meets the definition of EMC above. Such a determination has been viewed by Florida Courts as not being challengeable by the insurer and will unlock the $10,000 in PIP benefits. The definition of EMC is very broad and likely includes many injuries other than just broken bones, concussions, or lacerations.
There is no time limit to inform the insurer that you determined that a patient has an EMC. In cases where the auto insurer has limited benefits to $2,500 and the insurer is claiming they need an EMC determination, hospital facilities can have the patient records reviewed weeks, months, or even years later to determine if an EMC existed and submit such a determination after the fact to the auto insurer in order to secure the $10,000 in PIP benefits. Such a review and determination can be done by any qualified physician, ARNP, or PA (even if that health care professional merely reviewed the medical records to issue the certification and did not actually treat or see the patient). In fact, there are even third party vendor services who offer EMC review services. Remember, don’t take the insurer’s denial at face value. ER physicians hold the key to the increased PIP limits in a hospital setting.
