If someone’s carelessness caused your injury in a Florida car or truck crash, you want to get your medical bills paid.
The Notification Of Personal Injury Protection Benefits, written by the Florida Office of Insurance Regulation, talks about your personal injury protection rights and benefits under the Florida Motor Vehicle No-Fault Law.
It talks about the two things that the Florida Motor Vehicle No-Fault Law does, who is covered, medical payments, disability benefits, death benefits and optional deductibles and limitations.
That article does not explain the limited exception from liability for injuries caused to others in an automobile accident.
Basically, it does not explain how a negligent party can sometimes be exempt from liability for injuries caused to others. I discuss this further below.
What is “full coverage?”
“Full coverage” is a vague and misleading term. Some Florida auto insurance agents or consumers use the term “full coverage” when describing car insurance. Attorneys and claims adjusters do not use this term because it does not have any legal meaning.
However, the “street” meaning is that it is referring to PIP coverage that a resident of Florida who owns a motor vehicle is required to purchase.
It also denotes the minimum requirement of $10,000 in property damage/physical damage (PD) auto insurance.
Basically, when people use the term “full coverage”, they are referring to minimum coverage that you can purchase on a Florida personal auto policy to be in compliance with the law.
If you have “full coverage” and want your medical bills paid, you should understand the following:
Personal Injury Protection (PIP) or No-Fault Coverage
Personal Injury Protection (PIP) is also known as No-Fault Coverage.
PIP applies regardless of fault
If you were injured in a motor vehicle accident and you are covered by Florida PIP, then the minimum limits for no-fault personal injury protection benefits are:
- $10,000 per person for loss resulting from bodily injury, sickness, or disease arising out of the ownership, maintenance, or use of a motor vehicle if a physician, dentist, physician assistant, or advanced registered nurse practitioner has determined that the injured person had an emergency medical condition,
- $2,500 per person for loss resulting from bodily injury, sickness, or disease arising out of the ownership, maintenance, or use of a motor vehicle if a physician, dentist, chiropractic physician, physician assistant, advanced registered nurse practitioner, physical therapist or person licensed to provide emergency transportation and treatment has determined that the injured person did not have an emergency medical condition,
- Disability benefits, which combined with medical benefits cannot exceed $10,000, and
- $5,000 per individual for death benefits.
Tip: The best way to find out whether you are entitled to PIP coverage is to send an email, fax and letter to the first party auto insurer which asks them to disclose certain insurance information.
Remember: Even if you did not own a car in Florida at the time of the accident, you may still be considered an insured and thus covered under PIP in their auto insurance policy.
Tip: If you did not own a car but you are eligible to be covered under another car owner’s PIP auto insurance, then you should immediately complete a statement of non-ownership and send it to the proper insurer(s).
This will get the ball rolling so that your medical expenses and/or lost wages will hopefully get paid quickly.
Some injured victims are covered under Florida PIP and have additional first party coverage. Additional first party coverage may include health insurance.
Make sure that all the medical providers bill PIP. Otherwise, the PIP insurer may argue that they do not have to pay the health insurance.
Medical Expenses under PIP Coverage
PIP medical benefits pays 80 percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices and medically necessary ambulance, hospital and nursing services.
Medical benefits are only paid if the individual receives initial services and care within 14 days after the motor vehicle accident.
Medical benefits do not include massage or acupuncture, regardless of the person, entity, or licensee providing massage or acupuncture and a licensed massage therapist or licensed acupuncturist may not be reimbursed for medical benefits.
If you are not diagnosed with an emergency medical condition, your PIP insurance will pay up to $2,500 of your medical bills.
If you wait more than 14 days to see a doctor, your PIP insurance will not pay any of your medical bills. The formula to determine how much you will owe the hospital or doctor after your PIP insurance pays your bills is:
- 80% x total bill – your PIP deductible.
Tip: If a drunk driver’s negligence caused your injuries, and you are determined eligible pursuant to the Florida Crime Compensation Act (Florida Statutes 960.01 to 960.28), then any PIP or health insurance deductible that which you have does not apply to your medical treatment. Florida Statutes 624 .128. This can result in a huge savings.
Now, back to PIP in general. I have given a few examples to help you better understand how PIP works:
Example #1: $5,000 bill and you are not at fault
You were driving a car or were a passenger in a car involved in a car accident, and the other driver received a ticket for careless driving. Your hospital bill is $5,000.00. Let’s assume that you have auto insurance with State Farm.
If the hospital states that you have an emergency medical condition, your car insurance will pay the hospital is $4,000 (80% of $5,000). You would then owe the hospital $1,000. The formula is: 80% x total bill – your PIP deductible.
You can still make a claim against the at fault driver’s bodily injury insurance for the outstanding medical bills of $1,000.
This in addition to your claim for bodily injury, any resulting pain and suffering, disability and physical impairment, disfigurement, mental anguish, inconvenience or loss of capacity for the enjoyment of life experienced in the past or to be experienced in the future.
This is subject to certain exceptions and which is outside the scope of this article.
If the hospital does not state that you have an “emergency medical condition”, your car insurance will only pay the hospital $2,500 and you would owe the hospital $2,500.
Example #2: ($12,500 hospital or doctor bill)
You were driving a car or were a passenger in a car involved in a car accident, and the other driver received a ticket for careless driving.
Your hospital bill is in the amount of $12,500.00. If the hospital states that you have an emergency medical condition, your car insurance will pay the hospital $10,000 (80% of $12,500).
You would then owe the hospital $2,500. If you want to make a claim for lost wages from your car insurance policy, your auto insurance company will not pay you anything because your PIP insurance is exhausted.
You can make a claim against the at fault driver’s bodily injury insurance for the outstanding medical bills of $2,500 in addition to lost wages and pain and suffering.
If the hospital does not state that you have an emergency medical condition”, your car insurance will only pay the hospital $2,500. You would then owe the hospital $10,000.
You can make a claim against the at fault driver’s bodily injury insurance for the outstanding medical bills $10,000 in addition to lost wages and pain and suffering.
Example #3 – PIP Deductible and $5,000 bill:
You were driving a car or were a passenger in a car involved in a car accident, and the other driver received a ticket for careless driving. Your hospital bill is in the amount of $5,000.00.
Your PIP deductible is $1,000. If the hospital states that you have an emergency medical condition, your car insurance will pay the hospital $3,000 (80% of $5,000 -$1,000).
The formula is: 80% x total bill – your PIP deductible. You can make a claim against the at fault driver’s bodily injury insurance for the outstanding medical bills of $2,500 in addition to lost wages and pain and suffering.
If the hospital does not state that you have an emergency medical condition”, your car insurance will only pay the hospital $2,500.
Example #4 – PIP Deductible and $2,500 bill:
You were driving a car or were a passenger in a car involved in a car accident, and the other driver received a ticket for careless driving. Your hospital bill is in the amount of $2,500.00.
Your PIP deductible is $1,000. If the hospital states that you have an emergency medical condition, your car insurance will pay the hospital $1,000 (80% of $2,500 -$1,000).
The formula is: 80% x total bill – your PIP deductible. If the hospital does not state that you have an “emergency medical condition”, your car insurance will pay the same amount because it is less than $2,500 which is the limit if you do not have an emergency medical condition.
After your car insurance has paid $10,000 in PIP benefits, your auto insurance company does not have to pay for your medical bills under the PIP portion of your policy.
When you go the hospital or see a doctor, you should give your car insurance card to the medical provider.
If you have already set up a car claim with your car insurance company, you should provide the hospital or doctor with your claim number and the contact information for your insurance company.
If you didn’t give the hospital your car insurance card at the time of your visit, you should call them immediately and provide them with your car insurance information.
You should also ask the hospital for the contact information for the Emergency Room doctors. Call the ER doctors and give them your auto insurance information.
If you had an x-ray, CT scan, or MRI scan taken, ask the hospital for the contact information for the radiologist (person who interprets x-rays, CT scans, etc.).
Contact the radiologist’s office. Give them your car insurance information. This will help get your medical bills paid as fast as possible.
Tip: You should also give the hospital or doctor your health insurance (or Medicaid, Medicare, Tricare, VA insurance) if you have it. Your health insurance (or Medicaid, etc.) may pay for some of the medical bills that PIP does not pay for.
I talk more about first party coverage in a little bit.
If you have $10,000 in PIP coverage, why isn’t the PIP insurer covering my medical bills?
Sometimes PIP will not pay for your medical bills. The most common reasons are:
- The name insured made a material misrepresentation in the auto insurance policy application.
- The name insured and/or you failed to cooperate with the PIP insurers investigation. (This may include failing to attend an examination under oath or attend an independent medical examination (IME).
- You did not receive medical treatment within the fourteen (14) days following the accident.
- A doctor does not state, in writing, that you had an emergency medical condition.
- The PIP policyholder failed to tell the PIP insurer about additional people who reside in the household after the policy was purchased.
- The medical bills are not related to your injuries from the accident. (The PIP insurer may argue this in a minor impact collision.)
- The medical treatment is not necessary.
- The medical provider did not submit your medical bills to the PIP insurer within the applicable time frame.
Tip: The medical provider may be able to sue the PIP insurer. A jury may decide that the PIP insurer should have paid the medical bills.
A jury may not agree with the PIP insurer’s defense.
PIP for Floridians injured outside Florida
Medical Payments Coverage (Medpay)
An injured auto accident victim may have Medical payments coverage (“Medpay”) in his or her car insurance policy. Medpay is secondary to PIP coverage.
Medpay coverage is not required by law in Florida.
The excess medical expenses, the 20 percent not covered by PIP, and the deductible may or may not be covered by the additional medical payments coverage depending on your particular policy.
The Medpay insurer has a right of subrogation or reimbursement against a settlement with the tortfeasor. They have this right because it is written into every Florida auto insurance policy that I have seen.
The Medpay insurer does not have a right of subrogation or reimbursement against any settlement with an uninsured motorist (UM) liability carrier. (I talk about this further below in the UM liability coverage section.)
The injured person should send a letter, via certified mail, to the first party auto insurer. It should request that they state in writing (within 30 days) whether they are claiming a right of subrogation for Medpay benefits paid.
If they fail to respond in writing and claim a right of subrogation for Medpay benefits within 30 days of receipt of your written request sent via certified mail, then you do not need to the medpay lien.
Remember: The letter must be sent certified mail or the first party auto insurer’s failure to respond within 30 days will not waive their lien on medpay coverage.
If you are an occupant of a car and you were injured while working in Florida, then workers compensation is the primary coverage that will pay for your medical bills so long as you treat with doctors to whom they refer you.
Workers compensation should pay 100% of your medical bills, and you should not have any unpaid medical bills so long as you treat with workers compensation doctors.
Workers compensation is primary to PIP and should be billed first. Even if workers compensation pays 100% of your hospital bills, you can use any PIP, to which you are an insured, to pay off the workers compensation lien.
This may result in putting more money in your pocket from your personal injury claim for bills, lost wages, pain, suffering from the careless driver’s BI insurance.
Example – Using PIP to pay off Workers Compensation Lien
Although workers compensation paid all of the hospital bills, I sent the PIP carrier, State Farm, the workers compensation lien and demanded that they pay the lien with the $10,000 in my client’s PIP benefits.
At first the PIP carrier refused to pay part of the workers compensation lien. I insisted that they pay the lien and shortly thereafter they changed their position and paid $10,000 towards to the workers compensation lien. This put and extra $10,000 in my client’s pocket.
You still have a claim against the careless driver for your future medical bills and other damages that workers compensation does not pay.
5. Other First Party Coverage (e.g. Health insurance, Medicare, Medicaid, etc.)
You should use any available first party coverage to pay your medical bills. Health insurance, Medicare and Medicaid are secondary to any PIP coverage to which you are an insured and which PIP should pay. This means that PIP should be billed and pay your medical providers before the health insurance, Medicaid or Medicare is billed and pays.
Although Florida hospitals and medical providers do not have to bill Medicare if someone’s carelessness caused your injuries in a car crash, most do. Medicare should be billed before Medicaid is billed.
There many reasons why a Medicare beneficiary should hire a lawyer if someone’s negligence caused his or her injury in a car or truck crash. Medicare will always reduce its lien by attorney’s fees and costs. This may result in a huge savings for you!
You may face criminal penalties, the loss of your Medicare benefits and/or Social Security if you do not satisfy Medicare’s lien after a car or truck crash after you reach a personal injury settlement.
Do the hospital and medical providers have to bill Medicaid if someone’s carelessness caused my Florida car or truck accident?
It depends. Unfortunately, in Florida hospitals do not have to bill Medicaid if someone’s carelessness causes your injury and there is another party who is a primary payer.
An example of a primary payer is the insurance company for the careless person who caused your accident.
Do Medicaid beneficiaries have to use it to get medical treatment after a Florida car accident?
Repaying Medicaid After a Florida Car or Truck Accident
If settle your personal injury case and you try to stiff Florida Medicaid on the bills that they paid, you could face criminal penalties, and lose your SSI and Medicaid benefits.
Tip: If you settle your Florida personal injury case with an attorney, you may have to repay Medicaid less money than if you are without a lawyer. This is because Florida Medicaid, in certain situations, reduces its lien by attorney’s fees and costs. This may result in a huge savings for you.
After Medical Provider Bills PIP, Should Then Bill Health Insurer
Once PIP pays a medical bill from a Florida car or truck crash, the medical provider (e.g. hospital, ambulance, ER physicians, etc.) should submit the medical bill to the health insurer.
PIP may pay more than the health insurer’s approved rate. If PIP pays more than the health insurer’s approved rate, the medical provider should waive the balance.
The injured person should not be worse off because he was an insured under a PIP policy that paid benefits.
Medical Provider Should Immediately Bill Health Insurer After PIP is exhausted
Once PIP is exhausted (used up), the medical provider should immediately bill the health insurer. You should be sure to immediately send your health insurer a letter from the PIP insurer stating that PIP is exhausted.
I have had many clients who did not give the hospital and/or doctor both their auto and their first party coverage at the time of their medical visit.
Sometimes by the time the first party coverage provider receives the medical bill, they deny the bill due to it being untimely submitted. If that happens, the patient may be stuck owing the bill.
You May Have to Repay Your Health Insurer or Face a Lawsuit, Loss of Health Benefits and Payments May be Reversed
If someone’s carelessness caused your car or truck crash, and your health insurer paid medical bills, you may have to repay your health insurer. There are all days seminars on this topic alone. If you do owe the health insurer and you fail to pay them, you can face a lawsuit, loss of health insurance and the payments that may made may be reversed which would leave you owing money.
Warning! The big takeaway is do NOT believe (until you know the law cold) that health insurance subrogation adjuster if he or she tells you that you have to repay them.
They may be dead wrong. I have found this to be the case before which resulted in my clients getting thousands of dollars in their pocket more than what we would have received if we listened to the subrogation adjuster.
Though there are no guarantees, this savings may cover the attorney’s fees and costs alone.
Whether you have to repay the health insurer will depend on whether you policy is a self-funded ERISA policy, an insured ERISA policy or a non-ERISA policy.
Warning! Do NOT automatically believe the health insurer if they tell you that your health insurance is a self-funded ERISA plan. Failure to understand this law cold can cost you a tremendous amount of money if the claimed lien is large.
6. Potential Defendants
There are at several parties who may be liable in an auto accident for your medical bills if their negligence causes injury to you. They may also be responsible for other damages but that it outside of the scope of this article.
Florida law allows the recovery of “the reasonable value or expense of hospitalization and medical and nursing care and treatment necessarily or reasonably obtained by the injured person in the past or to be so obtained in the future.” Fla. Std. Jury Instructions (Civil) 6.2b.
In Florida, the driver who was received a ticket for causing the crash is not automatically responsible for all of your medical bills.
The potential defendants are liable for the 20% of your medical bills that PIP doesn’t pay up to $10,000 if their negligence caused your injuries. If you want the potential defendants to pay 20% of your medical bills up to $10,000, you have to set up a claim with them.
The potential defendants may be liable for 100% of your damages – above the $10,000 – if their negligence caused your injury.
We generally email, fax and mail this letter to the potential defendant’s insurance company to request certain insurance information. The potential defendant is usually the negligent driver, or owner, of the vehicle that caused the crash.
7. Uninsured Motorist (UM) Liability Coverage in an Auto Insurance Policy.
If another driver’s carelessness caused your injury, then any policies of UM coverage to which you are an insured should pay for medical bills that are not paid under workers compensation, PIP, Medpay, or BI coverage.
The Medpay carrier may claim that they are entitled to recoup Medpay payments made pursuant to the auto insurance policy.
I send a written letter, email and fax to the Medpay carrier stating that they are not entitled to recoup Medpay payments made because Florida Statute 627.727(1) excludes from a UM recovery duplicate payments made under auto Medpay coverage. I cite the Florida Statute language which says:
“The coverage described under this section shall be over and above, but shall not duplicate, the benefits available to an insured under any workers’ compensation law, personal injury protection benefits, disability benefits law, or similar law; under any automobile medical expense coverage; under any motor vehicle liability insurance coverage; or from the owner or operator of the uninsured motor vehicle or any other person or organization jointly or severally liable together with such owner or operator for the accident.”
8. How Medical Bills Affect Personal Injury Case Settlement Value
Out of pocket medical bills increase the full value of a Florida injury case. In addition, the total billed medical charges affect the settlement value of a Florida personal injury case. If you have a serious injury, do not just plug the amount of your medical bills into a settlement calculator.
There are many reasons why you should not value your case based on an online settlement calculator. This is true whether you are looking at my Florida injury settlement calculator or one that someone else made.
9. Other Personal Injury damages.
Medical bills are one of the many damages that you may be able to recover in a Florida personal injury case. I invite you to learn more about whether you may be able to get money for pain and suffering if someone’s carelessness caused your injuries in a Florida car accident.
Did someone’s carelessness cause your injury in a Florida car crash or other type of accident?
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Editor’s Note: This post was originally published on March 2013 and has been completely revamped and updated.