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Analysis of CS/CS/HB 119 by Rep. Boyd (Bradenton)
PIP/No-Fault Automobile Insurance -- Florida Legislative Session 

 

Assuming it is approved by the Governor, which is almost certain, the new PIP bill takes effect on July 1, 2012, as to general provisions applicable to PIP policies such as EUOs for insureds, but the benefit limitations apply to PIP policies issues or renewed on or after July 1, 2012. That means that by June 30, 2013, all PIP policies will be replaces with this new type of policy. The bill passed by both the House and the Senate and does the following: 

  • The accident victim must seek treatment within 14 days of the accident.
    • The insured is allowed to seek his/her full $10,000 in PIP benefits only if he/she is diagnosed with an "Emergency Medical Condition."
    • "Emergency Medical Condition" is defined as:
      • Acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:
        • SERIOUS jeopardy to patient health
        • SERIOUS impairment of bodily function
        • SERIOUS dysfunction of any bodily organ or part.
      • A chiropractor is excluded from being able to make that diagnosis of EMC; only M.D.s, D.O.s, P.As, and ARNPs are authorized to make that diagnosis.
      • A patient could get chiropractic and other follow-up care up to the $10,000 in benefits if the patient first gets a diagnosis of an EMC from an M.D., D.O., P.A., or ARNP. The Chiropractor is then allowed follow-up care for treatment limited to the initial diagnosis up to the full $10,000 in benefits.
    • If the insured is not diagnosed with an EMC or if the insured wants to seek treatment initially directly with the chiropractor, the patient gets to use up to $2,5000 in (reimbursed) PIP benefits.
    • The insured gets $0 in PIP benefits if he/she seeks treatment beyond the 14 days after the motor vehicle accident.
  • The bill will quite likely effectively limit sprain/strain diagnosed injuries to $2,500 in benefits. It is the undetermined at this time whether or not the insurer will attempt to override or dispute the treating physician's diagnosis of EMC. It is quite likely that even if the M.D., D.O., ARNP or P.A issues the EMC diagnosis in the medical records, that the Insurer will still deny that an EMC exists and limit the patient's benefits to $2,500. 
  • Diagnostics: While the bill appears to include diagnostics in the $2,500 limitation ("reimbursement for 'services and care',) the bill still has some ambiguity in that regard.
  • Tolling payment of benefits: The insurance company gets an additional 60 days to pay benefits if it "suspects" insurnace fraud. There is no definition of what "suspect" requires.
  • Medicare Coding Policies: The bill allows the insurer to use Medicare coding policies and payment methodologies of CMS, including applicable modifiers (not utilization limits,) to further reduce bills.
  • PIP Log: While the bill requires an isurer to furnish a PIP log to the insured or provider, it only must do so "if litigation commences." This was not a big loss for insurance company as they are now requires to produce a PIP log once suit has been filed.
  • Examinations Under Oath: An insured and omnibus insured (passenger) must sit for an Examination Under Oath ("EUO") as a "condition precedent" to receiving benefits. In other words, before the doctor gets paid for his/her services, the patient has to sit, if requested by the insurance company, for the EUO.
  • Attorney's Fees: No attorneys fee multipliers are allowed. This resulted in a reversal of current case law and a big win for auto insurers who sometimes were actually deterred from frivolously denying lawsuits when a multiplier was at risk.
  • Illusory rate reductions: The bill failed to incorporate the Senate's 25% rate rollback for consumers and, instead, replaces it with a vague and ambiguous provision that does not guarantee ANY premium reduction for consumers.

*If you have been in an accident within the past two weeks, you should be aware that a recent law requires you to be seen by a doctor within 14 days of the accident or your insurance will not pay for your treatment.

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