Denied Payment as the Claimant
We regularly come across claims wherein a Florida physician has been denied payment as the claimant has exceeded $2500.00 in medical bills and the treating physicians have not expressly used the term "Emergency Medical Condition" in their notes. In fact, in many of our claims; the objective records supplied by the medical provider(s) paints a clear picture that the patient/claimant has suffered an injury that clearly meets the threshold of an EMC. The insurance carriers have consistently ignored such records. In fact, the only claims we have noted the applicable carrier paying in excess of $2500.00 in no-fault benefits is when a treating physician expressly used the three magical words; emergency medical condition. Florida auto insurance carriers have uniformly adopted the self serving interpretation of the amended PIP statute by adhering to a shift of burden that the Statute fails to make mention of. PIP Claims Adjusters are refusing to reimburse on bills once the $2500.00 threshold has been met absent an expressed statement from a licensed physician that the patient has sustained an EMC. Florida's PIP Statute does not state a physician must find or make a determination of an EMC. Unfortunately for insurance carriers, the Statute only provides clear guidance on what takes place if a physician determines that an EMC exists or there is a lack thereof. Statutory construction requires strict interpretation of an existing Statute. In order for a Judge to side with an insurance carrier on this issue requires a finding on the record that an EMC must be determined by the treating physician, the term "Emergency Medical Condition" must be expressly stated within the language of the medical report, and the handling Claims Adjuster is not required to exercise a duty of due diligence in their investigation of the claim and the medical records provided. As previously stated, Florida Statute is silent as to what happens if there is no determination of an EMC. The statute clearly spells out what takes place if there is a determination of an EMC (i.e., $10,000.00 in benefits) and what happens if there is a determination there is NO EMC (i.e., $2500.00 in benefits). The Statute makes no mention or reference to a requirement that a physician must expressly state the term ‘emergency medical condition.' In accordance with Florida Administrative Code, the adjuster must diligently investigate the claim. Further, the Claims Adjuster must review the records and make a determination as to whether then claimant's symptoms are of such severity that in the absence of immediate medical attention, could reasonably be expected to result in serious jeopardy to their health, serious impairment to a bodily function or serious dysfunction of a bodily organ or part. Dolman Law Group Accident Injury Lawyers, PA 800 North Belcher Road Clearwater, FL 33765