Why is my insurance company denying my $10,000.00 in PIP benefits?

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Why is my insurance company denying my $10,000.00 in PIP benefits?

by | Jul 24, 2015 | Personal Injury

“I thought my Personal Injury Protection benefits covered up to $10,000 dollars of my medical expenses!”

Don’t be fooled! Just because you pay for $10,000.00 of personal injury protection (PIP) coverage doesn’t mean you are always eligible to receive that amount in full. In order to qualify for the full $10,000.00 in PIP benefits, the new PIP statute requires that an individual have suffered an “emergency medical condition” (or “EMC”) as a result of the motor vehicle accident. If you are not diagnosed as having suffered an emergency medical condition, you may only qualify for a limited $2,500 of PIP benefits.

Florida Statutes defines an emergency medical condition 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: serious jeopardy to patient health; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.”

These terms are not necessarily easy to understand. To determine how serious your injuries are, ask yourself: Am I having difficulty walking? Am I having difficulty turning my neck? Has taking over the counter medication relieved my pain? Make sure to ask yourself these questions so that you are prepared to let your physician know how you are feeling when you go in for your initial consultation. Remember, you must seek medical attention within 14 days after the motor vehicle accident in order to receive any PIP benefits!

When seeking treatment it is also important to know that not every health care provider can determine if you have an emergency medical condition. It is important that you seek treatment from a medical doctor, doctor of osteopathy, physician’s assistant or advanced registered nurse practitioner as these are the health care providers who are legally authorized to determine whether you suffered an emergency medical condition as a result of the motor vehicle accident.

If you were not diagnosed with an emergency medical condition at the initial consultation, but you continue to seek treatment, the PIP Statute does not prohibit a doctor from determining your condition at a later date.

If a doctor has not addressed the emergency medical condition on your initial office visit or in any of your follow up visits, this does not necessarily mean that you have not suffered an emergency medical condition. That term is more commonly used in the legal setting to define the severity of your injuries and limit the amount of benefits you can recover. It is a legal term, not a medical term, and some doctors, particularly, those not familiar with the PIP Statute, may not identify it as such on your consultation notes. That is why it is important to seek medical attention from a provider that knows PIP Statute. DO NOT be alarmed if a doctor did not make a determination of an emergency medical condition, but DO contact Pacin Levine at (888) 450-4909 to get more information as to how a diagnosis of an emergency medical condition can affect your entitlement to PIP benefits.

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