The Florida legislature enacted the Motor Vehicle No-Fault Law, which provides Personal Injury Protection (PIP) benefits to those injured in a car accident. The benefits under Fla. Stat. § 627.736(1) allow motorists injured in a car accident to receive up to $10,000 in medical and disability benefits if the injured person suffered from bodily injury, sickness, disease, or death from owning, maintaining, or using a motor vehicle. To receive the maximum amount, there must be a determination that there is an emergency medical condition. Otherwise, the benefits are limited to $2,500. In Medical Center of the Palm Beaches vs. USAA Casualty Insurance Co. (No. 4D14-3580), the Fourth District Court of Appeal looked at what should happen when there is no determination of an emergency medical condition.
The injured driver in this case suffered from pain to her right shoulder and cervical region after a car accident. A treating physician referred her to a physical therapy practice, which then submitted bills to the insurer. The injured person’s insurance company refused to pay, explaining that the injured woman had already met her $2,500 limit. The insurer, in its denial, requested a determination of the injured person’s emergency medical condition by an authorized provider. The physical therapist office sued the insurer for breach of contract for not paying the bill presented to them. Moreover, the same office also sent a note from the injured person’s treating physician, who diagnosed her with an emergency medical condition. The insurance company then paid all outstanding charges until the $10,000 limit was reached.
The trial court ruled in the defendant insurer’s favor on summary judgment, agreeing with the insurer that the limit is $2,500 in the absence of a determination of an emergency medical condition. The court also ruled that the defendant did not waive any defenses because it reimbursed the physical therapist office following the determination. The physical therapist office appealed, arguing that the opposite should occur. The office argued that the statute only limits the payment to $2,500 when a statutorily authorized provider determines there is no emergency medical condition. The physical therapist office’s position was that the default should be payment up to $10,000 in the absence of a negation.
The appellate court disagreed, looking toward the statute itself to establish legislative intent. The wording of the statute first limits the benefit to $10,000 for an emergency medical condition. The statute then limits the benefit to $2,500 when there’s been affirmative proof there was no emergency medical condition. The statute does not address the specific situation of no determination at all. In its ruling, the appellate court looked to a federal circuit court case, Robbins v. Garrison Property & Casualty Ins. Co., in which no medical provider made any determination regarding an emergency medical condition in two separate cases. In that case, the Eleventh Circuit looked to legislative history that showed the legislative body wanted to reduce payments of fraudulent claims. The federal court concluded an affirmative determination must be made to raise the limit from $2,500 to $10,000. The Florida District Court of Appeal agreed. The court also made sure to address the difference from the present case, in which payment was made after a determination of an emergency medical condition was acquired by the insurer. The court ruled that the insurer had the right to request a determination before issuing any payment. The summary judgment in favor of the insurer was affirmed.
All Florida car accident victims rely on prompt payment of benefits under one’s insurance policy. The attorneys at Donaldson & Weston can assist you with your car accident claim. Contact our office today at 772-266-5555 or 561-299-3999 for a free, confidential consultation.
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