Many people have a misconception as to what the “No-Fault” Law actually is. Most people believe that the “No-Fault” law means that if there is an accident no one is at fault, which is fundamentally untrue. What the “No-Fault” law does is require drivers to carry a certain amount personal injury protection, which allows for quick and effective compensation, regardless of fault. The trade-off is a limitation on the right to sue for noneconomic damages, or pain and suffering. This year, there have been several reforms made to this law, which has been in effect since January 1, 1972. You can find the entire “No-Fault” Law Outlined in Florida Statute 627.730-627.7405 .
The changes are outlined below:
I. Changes in Medical Benefit Restrictions and Limitations ( Florida Statute 627.733)
A. Policyholder must seek medical care within 14 days of injury to file a PIP claim. They must be treated in an emergency room, by emergency personnel, or by someone with an MD, DO, DC, or DDS designation.
B. All medical coverage is limited to $2500, unless they have an “Emergency Medical Condition.” An EMC is defined as something that (i) seriously jeopardizes the patient’s health, (ii) causes a serious impairment to bodily function, or (iii) causes serious dysfunction of any bodily organ or body part.
C. Medical coverage limited to initial injury diagnosis. PIP only covers follow-up treatment to injuries initially diagnosed. Anything diagnosed at a later date does not apply.
D. Massage and Acupuncture are no longer considered medical expenses to be covered.
E. Effective March 1 of each year, the applicable fee schedule or payment limitations apply until any changes that occur the following March 1.
F. Provider may resubmit a bill within 15 days if it is found to have an error that needs correction.
II. Changes in Exemption for Clinic Licensure ( Florida Statute 400.995 )
Effective January 1, 2013, failure to obtain a required clinic licensure makes all charges NOT reimbursable under PIP coverage. This means that if the facility where you received medical treatment does not have the correct licenses, your medical bills will not be reimbursed, so make sure you are seeing an eligible physician.
III. Consequences for Healthcare Providers Convicted of Fraud ( Florida Statute 817.234 )
If a healthcare provider is convicted of PIP fraud, they will lose their medical license for 5 years, and be unable to receive PIP reimbursement for 10 years, as of July 1.
IV. Ability to Obtain ledger of Insurance Payments: The insurer must provide copies of all records of payment made within 30 days if the claim goes to litigation.
V. Notifications associated with PIP Benefits being exhausted ( Florida Statute 627.7401 )
Insurers have 15 days to notify the policyholder if the limit has been reached. You and your healthcare provider should request immediate notification, if you don’t want to exceed the limit and pay the difference.
VI. Changes to requirements of Insured “complying with terms of policy” This requires the policyholder to have an examination under oath at the request of the insurer.
VII. Failure to Appear for Exams ( Florida Statute 626.736(6) )
If you fail to appear twice for a PIP Independent Medical Exam (IME), you create the presumption that the insured’s refusal was unreasonable.
VIII. Additional time to Pay Claims ( Florida Statute 627.732(2) )
Insurers have an additional 60 days to pay a claim if fraud is suspected.
IX. No Payments Owed ( Florida Statute 817.505 )
No payments are owed if there is a brokering of a split-fee or kickback arrangement. This is considered fraud.
X. Death Benefits ( Florida Statute 627.736 )
There is a $5,000 death benefit under PIP. Reformed PIP allows for $10,000 to cover medical bills incurred if they meet EMC standards.
XI. Elimination of Contingency Fee Risk Multipliers Attorney Fee award must (a) comply with professional standards, and (b) not overstate or inflate the number of hours spent on a case.
XII. Electronic Communication ( Florida Statute 627.736(16) )
Electronic forms of communication are now acceptable as long as all data is transferred securely
XIII. Rate Reductions PIP Premium rates must be reduced by 25% unless there is “clear and convincing” evidence to justify a lesser reduction, by January 1, 2014.
Representatives for the insurance companies that initiated the changes being made to the Florida “No Fault” Law did so with the spoken intention of lowering insurance premiums, while protecting the companies against fraud. Whether premium prices will go down has yet to be seen. If you have been in a car accident, consult with an attorney before receiving any major medical treatment, as once your PIP benefits have been exhausted, they cannot be restored.