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Subrogation Blog

State Subrogation Laws: How Does PIP Coverage Work in Florida?

Posted on 01/08/2024 - 6:00 AM by

This article is a companion piece to this video

In this episode of On Subrogation: Florida PIP Emergency Medical Condition, subrogation attorney Jason Sullivan discusses how the amount of a PIP claim payout is determined, and how subrogation professionals can effectively defend those payouts during pursuit of recovery from the tortfeasor or their carrier.

For a primer on PIP subrogation in Florida, watch our episode On Subrogation: Florida PIP Subrogation.

PIP Subrogation in a No-Fault State: Can You Recover?

Personal Injury Protection is a type of auto insurance coverage that pays expenses associated with being injured regardless of who, if anyone, was at fault. These include medical expenses, but also associated expenses like lost wages, rehabilitation, funeral expenses, etc.

PIP is most often required in no-fault states where drivers pursue recovery via their insurer, who then subrogates against the responsible party. Florida is a particularly strict no-fault state; they bar insurers right to recover PIP expenses paid out to their insured except in very specific circumstances. This is opposed to at-fault states – like Texas’ subrogation laws for PIP, which allow insurers to pursue at-fault parties so long as their insured has been paid.

PIP subrogation can be a tricky and expensive endeavor, especially in states like Florida, who don’t allow PIP insurers to recover from liable parties almost under any circumstances. This then becomes even more challenging when a subrogating party encounters an emergency medical claim in the course of a case.

Florida PIP Coverage & Emergency Medical Conditions

PIP coverage (Personal Injury Protection) is required in all auto insurance policies in the state of Florida. PIP covers 80% of reasonable medical expenses resulting from a collision, 60% of lost wages, and death benefits of up to $5000. It can also include travel expenses associated with medical visits and may apply to both initial and ongoing treatment. However, PIP caps at $2500 unless there is an emergency medication condition, in which case PIP caps at $10000. If medical expenses exceed PIP coverage, drivers must resort to bodily injury claims and health insurance policies.

To be entitled to the $2500 PIP coverage, your insured must receive initial treatment within 14 days of the injury from a(n):

  • Hospital/hospital facility
  • Licensed physician
  • Chiropractor
  • Dentist
  • Advanced practice registered nurse

The difference in whether the insured is entitled to $2500 or $10000 is the existence of an emergency medical condition. In Florida PIP insurance, an emergency medical condition is defined as:

  • Acute symptoms of sufficient severity including pain
  • In the absence of immediate medical attention, it is reasonably expected you would have:
    • Serious jeopardy of health
    • Serious impairment of bodily function, or
    • Serious dysfunction of organ(s) or body part(s)
  • The diagnosis of this emergency condition must come from an appropriately authorized individual:
    • Licensed physician
    • Dentist
    • Physician’s assistant
    • Advanced practice registered nurse

Implications & Impacts of Florida’s PIP Subrogation Laws

The general rule in Florida is there is no right to subrogate PIP expenses (§627.7405). The rule is meant to reduce litigation by ensuring each driver’s own insurer pays personal injury claims. However, these restrictions not only put undue stress on insurers, but have also led to high rates of PIP fraud and litigation over improper claims.

There are rare exceptions to the general rule, though. Carriers looking at subrogation potential in PIP claims should be aware of Florida’s specific subrogation laws for personal injury, as there are a few important limitations:

  • If an FL resident is injured in an accident that happened in an at-fault state, an insurer can pursue the at-fault party via subrogation.
  • If a non-FL resident causes the accident, the insurer may have a right to subrogation recovery if the at-fault driver’s policy includes out-of-state liability coverage.
  • If it’s a workers compensation claim that covers medical expenses, the insurer may pursue the workers compensation carrier for the PIP expenses.

A couple other intricacies of Florida PIP subrogation laws:

  • If a driver decides to sue the at-fault party, the defendant’s insurer can reduce the driver’s claim by their PIP payout. This doesn’t repay the PIP insurer, but it prevents double recovery by the driver.
  • If multiple insurers cover medical expenses, one may pursue another under a contribution claim, which can lessen the extent of loss from the PIP payout.

It’s these complex and restrictive environments where it’s especially important to have subrogation attorneys experienced in specific jurisdictions, including actively monitoring legislative changes that affect these slim opportunities for subrogation recovery.

Hypothetical Case Study: Navigating PIP Subrogation Claims in Florida

Consider a hypothetical: You have a subrogation dispute for a PIP claim that meets the commercial vehicle exception. An emergency condition existed, and you paid out well over $2500. Now, the other carrier is disputing whether you should have paid PIP at all, and if the $10000 emergency condition truly existed.

The answer should be simple. Once it is confirmed the commercial vehicle exception applies, you have two questions to ask:

  • Did the insured seek medical treatment from an authorized source within 14 days of the incident? If so, they were entitled to a PIP payout up to $2500.
  • Was the insured diagnosed with an emergency medical condition by the appropriate medical professional(s)? If so, they were entitled to a PIP payout up to $10000.

The next defense will often be, where is the emergency medical diagnosis? What is your proof? This is another part of Florida PIP subrogation that can get muddy. There are no standard forms or lists for how a diagnosis must be formatted or which conditions count. 

The good news is that the actual diagnosis used in your subrogation claim does not need to have happened within 14 days of the incident; the 14 days only applies to the initial treatment. Provided the correct medical records exist, you can go back to the attending doctor a year after the incident to confirm an emergency condition did, in fact exist.

Final Tips for Florida Attorneys Subrogating a PIP Claim

In short, after paying out a PIP claim, counsel managing the claim should ask themselves:

  • What is the argument that there is no PIP subrogation?
  • If an exception applies, ask:
  • What exactly is the dispute?

As is the shadowy nature of subrogation, state statutes limiting subrogation rights can make the field complicated. Florida’s severe restrictions on PIP subrogation make it difficult for insurers to recover claims except in out-of-state incidents, non-resident drivers, or workers compensation subrogation. Careful case management of potential PIP subrogation claims is key in no-fault states like Florida.

The Advantage of Retaining a National Subrogation Law Firm

Regardless of jurisdiction, insurance attorneys should remember that, even if the conditions seem difficult, there is almost always potential for subrogation. Carriers should retain a subrogation law firm with attorneys licensed in specific jurisdictions to ensure that, no matter the legal environment, their chances of recovering damages are always maximized.

For more information on subrogation and insurance law, visit Rathbone Group’s YouTube channel and podcast library for more episodes of On Subrogation. Can’t find what you’re looking for? Suggest a topic for a new episode by emailing us at video@rathbonegroup.com or podcast@rathbonegroup.com.