In most Florida auto accidents, your health insurance will pay your medical bills after Personal Injury Protection (PIP) coverage from the auto insurance policy has been billed.
Health Insurance is Usually Secondary in Most Florida Auto Accidents
Therefore, PIP is usually primary in most Florida auto accidents.
When is PIP primary in Florida auto accidents?
PIP is primary when the injured person was in a vehicle that is considered a “motor vehicle” under Florida’s No-Fault law. The most common vehicles that fall under the “motor vehicle” category under Florida PIP law are private and commercial cars, and trucks.
PIP is also primary when the injured person is considered a Florida resident “pedestrian” and a “motor vehicle” (as defined under the PIP law) hits him or her.
Below is an example that shows the interplay between PIP and health insurance in Florida auto accident claims.
Example #1 – Health Insurance Pays After PIP is Billed
Mike is visiting Coconut Grove, Miami-Dade County, Florida. He is placing a paid parking ticket receipt into the dashboard of his rental car.
Another car changes lanes and crashes into Mike, and he suffers a lower leg bone (tibia) fracture. Mike’s hospital bills are $130,000.
Since Mike is placing a ticket into his dashboard, he is considered an occupant of the rental car. Therefore, the rental car’s PIP pays up to $10,000 in benefits before Mike’s health insurance pays the remainder of the medical bills according to the health insurance policy.
Medical Provider Should Immediately Bill Health Insurer After PIP is exhausted
Once PIP is billed and pays, the medical provider should immediately bill the health insurer. The injured person should be sure to immediately send his or her health insurer a letter from the PIP insurer stating that PIP has been billed, and that it paid the medical provider.
I have had many clients who did not give both their auto and their first party coverage to the hospital and/or doctor at the time of their medical visit.
What happens if you wait too long to give your health insurance to your medical providers after a Florida auto wreck?
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 injured person may be stuck owing the bill.
This is why it is important to make sure that all of your medical providers also have your health insurance information if you are injured in a Florida motor vehicle accident.
If they have your health insurance information, then once PIP pays a medical bill from a Florida car or truck crash, the medical provider (e.g. hospital, ambulance, ER physicians, etc.) can submit the medical bill to the health insurer.
Claimant Does Not Owe More than Amount Allowed Under the Health Insurance Contract
If PIP paid more than the hospitals contracted rate with the health insurer, then the medical provider should waive the balance.
Example #2 – Injured Person doesn’t owe medical providers more than health insurance would’ve paid
A DUI driver hits Michelle in Miami, Florida. Michelle goes to the Emergency Room and her bills are $30,000. PIP pays the hospital $10,000.
Normally, Michelle would owe the hospital, at least, the 20% that PIP did not cover which would be $2,000.
Assume that Erika’s health insurer has a contract with the hospital that says that the agreed upon charge for the all of the treatment that she received is $7,000. To keep it simple, I’ll assume that her health insurance pays 100% of the agreed rate.
In this case, PIP paid the hospital $3,000 more than the agreed upon rate.
Since the hospital has a $3,000 credit, and Erika would not owe the hospital any money. She benefited by having health insurance.
The reason for the zero balance is that the injured person should not penalized for having PIP, if he or she already has health insurance.
Tip: If a DUI driver’s carelessness caused your injury, 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 big savings.
Claimant Can Make a Personal Injury Claim for Out of Pocket Bills and Liens
Example #3 – How to Get Your Out of Pocket Medical Bills Paid
Let’s look at example #1 again, which involved a driver of a car crashing into Mike in Florida. Mike’s hospital bills are $130,000.
PIP pays $10,000. Mike’s his health insurance pays $115,000 pursuant to his health insurance policy. After PIP and health insurance pay, he owes the hospital $5,000.
If Mike is stuck owing the hospital $5,000 after PIP and the health insurer pay the bills according to the policies, Mike can make a claim against the prospective defendants for $5,000 in addition to the other damages.
If Mike’s health insurance contract includes a right of subrogation (right to be repaid), then Mike can also make a claim against the liable parties to recover the amount that the health insurer paid.
So if Mike’s health insurance paid the hospital $115,000, and the health insurance policy has a right of subrogation, then Mike can recover this $115,000, and the hospital remaining balance of $5,000, against the prospective defendants.
All the settlements in this article are before deduction for attorney’s fees and expenses. Most cases result in a lower recovery. It should not be assumed that your case will have as beneficial a result.
You May Have to Repay Your Health Insurer or Face Huge Penalties
If someone’s carelessness caused your car or truck crash in Florida and you settle a personal injury claim, and your health insurer has a right of subrogation, then you may have to repay your health insurer.
There are all day seminars on this topic alone. If you fail to honor the health insurer’s subrogation right, then:
- You can face a lawsuit to recoup this money.
- You may also lose your health insurance.
- The payments that it made may be reversed which would leave you owing money.
Warning! Do NOT believe (until you know the law cold) the health insurance subrogation adjuster if he or she tells you that you have to repay them. They may be dead wrong.
I have dealt with health insurance subrogation adjusters who have asked to be fully repaid for health insurance payments made. In several cases, these adjuster were wrong.
The fact that I knew Florida health insurance subrogation law very well resulted in my clients getting many more thousands of dollars in their pocket.
If I listened to the health insurance subrogation adjuster, we would have settled for less money.
Some health insurance plans are required to reduce their lien, at a minimum, by your attorney’s fees and costs.
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 subrogation adjuster if they tell you that your health insurance is a self-funded ERISA plan. They may be dead wrong.
I have heard countless stories of them either lying or incorrectly advising injured people on the law. Failure to understand this law cold can cost you a tremendous amount of money if the claimed lien is large.
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I want to represent you if you were hurt in an accident in Florida. If you were injured in another state but live in Florida, I may also be able to represent you.
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