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.

How Does PIP Coverage Work in Florida?

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, and may apply to both initial and ongoing treatment. For non-emergency medical conditions, PIP caps at $2500. For emergency medication conditions, PIP caps at $10000.

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

Navigating PIP Subrogation Claims in Florida

So, how do these criteria apply when pursuing subrogation recovery from the tortfeasor/insurer? 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. However, 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 [email protected] or [email protected].