No-Fault (PIP) Benefits In Florida, Explained By A Lawyer

How Do No-Fault (PIP) Benefits in Florida Work?

Do You Pay For Your Medical Bills After An Accident In Florida?

No-fault benefits are paid from YOUR insurance company regardless of fault for an accident. It may seem unfair that YOUR insurance company has to pay for your medical bills after an accident that was SOMEONE ELSE’s fault, but that is why it is called “no-fault” insurance and it is the law in Florida (it is not supposed to matter whether the accident your fault or the other person’s fault). Another popular misconception is that “no-fault” coverage only applies when the accident is NOT your fault. This confuses “not at fault” with “regardless of fault.”

The public policy behind this is that the Legislature wanted to provide a baseline for medical and death benefits to everyone involved in car accidents in Florida without having to prove that another person is legally liable.

In doing so, the benefits are supposed to be paid faster, usually within a few weeks of receiving the bill. Insurance companies that do not pay PIP benefits to medical providers on time are subject to interest and penalties if a PIP lawsuit is filed by the medical provider.

How Much Is My Florida No-Fault Benefit?

Ever since the Florida no-fault statute (section 627.736, Fla. Stat.) was amended in 2007, I have not seen PIP policy limits greater than $10,000 per person. Prior to 2007, I had seen several policies where the policyholders had $50,000 per person and $100,000 per person in PIP benefits.

However, after 2007, I have only seen an “added PIP” addendum and an “extended PIP” addendum that is addressed below. To purchase added PIP, you must first typically purchase extended PIP. Added PIP increases your overall coverage limit.

No-fault benefits are paid at 80/20 of the allowable fee schedule (200% of Medicare fee for service schedules). This means that a medical provider getting paid under PIP can be paid 80% of 2-times what Medicare would pay for the same service. Any more than that is not allowed under the fee schedules and the patient is not responsible to pay (see section 627.736, Fla. Stat.).

There is a $5,000 death benefit that can be paid to the estate of the decedent, next of kin, a funeral home, or anyone who has actually paid burial expenses on behalf of the decedent. This $5,000 death benefit is not affected by whether medical expenses were paid to a hospital prior to death.

What Does My No-Fault Benefit Pay Towards Medical Bills?

Your PIP or no-fault benefits will pay 80% of your medical bills according to the Medicare fee for service payment schedule referenced in section 627.736, Fla. Stat. Unless you have extended PIP or medical payments coverage, then you are responsible to pay the 20% balance that is not covered under PIP.

Your Medical Providers May Take You To Collections On The 20% Balance Even When The Accident Was Not Your Fault

If you cannot or do not pay the 20% balance after PIP has paid its portion, a medical provider (usually a hospital, large clinic, or EMS service) has the right to take you to collections. This hurts your credit rating.

If you do not want unpaid medical bills to impact your credit rating after a car accident, you should work out a minimum payment plan with the medical provider. If you do not have perfect credit, then it may not matter so much if you get taken to collections over the balance.

Whether to pay these balances after being taken to collections is a decision that you will make with your personal injury attorney when a settlement is reached on your case, although you are always encouraged to pay debts that you rightfully owe.

Should I Buy Medical Payments Coverage Or Extended PIP?

If you do not want to be responsible to pay the 20% unpaid balance after PIP pays its 80%, then you have the option to purchase either medical payments coverage or extended PIP when you purchase your policy. If you would like to have these coverages, you should contact your insurance agent to add them to your policy. You must have them in place before an accident happens as any changes after an accident won’t be effective for your claim.

Medical payments coverage (also sometimes called “MedPay”) can be used to cover the 20% unpaid balance or 100% of any other medical balances. Ideally, your PIP/MedPay adjuster should apply only 20% of your medical payments coverage toward your medical bills until your PIP benefits become exhausted. I have seen cases where the PIP/MedPay adjuster will use 100% of the medical payments coverage before paying PIP benefits.

If you find out that this is happening (by looking at the explanations of benefits for each payment), then you should call your PIP/MedPay adjuster to correct the issue. This is important because you do not want 100% of your medical payments to be used up before your PIP benefits pay their part. This would leave you with the unwanted balance that you had hoped to avoid.

In addition, there is contractual right of subrogation or reimbursement with medical payments coverage under most policies. This means that you have to repay it when you receive a settlement (I know, it’s not really a good deal). A personal injury attorney can help you reduce the repayment or eliminate it altogether if you also purchased UM coverage.

Perhaps a better way to ensure that 100% of medical expenses are paid after a car accident in Florida is to purchase extended PIP. Extended PIP covers 100% of your medical bills and does not have to be repaid, which gives it a clear advantage over medical payments coverage. As discussed above, you can purchase “added PIP” (which increases your limit) if you have purchased “extended PIP” with many insurance companies (some insurance companies do not offer this coverage).

Finally, if you have an adequate health insurance policy, then medical payments coverage, “extended PIP,” or “added PIP” may not be important or necessary. This type of automobile insurance coverage can only be used if you get hurt in an auto accident, whereas, health insurance applies to any illness that you may have and may be a better buy depending on your circumstances. When you are buying insurance, it is a balancing act of risk versus the cost of the premium. Here is what insurance you really need.

How Long Do I Have To Make A Florida PIP Claim?

You have 14 days after a car accident to get treatment for a Florida no-fault claim. If you do not obtain medical treatment within the first 14 days, then your PIP carrier is not required by Florida law to extend PIP benefits to you for the accident, even if you decide later that you are in need of medical care from the accident.

Further, you have three years under most Personal Injury Protection automobile policies to get treatment (assuming that you sought initial treatment during the first 14 days after the accident). For medical treatment extending beyond three years, you will need private health insurance, Medicare, or medicaid to cover your expenses.

How Does A PIP Or No-Fault Deductible Work In Florida?

We recommend that you should never carry a PIP deductible because the amount that you save on premium does not typically justify the extra amount that you have to pay if you have a claim. PIP deductibles are normally $500, $1,000, or $2,000. By Florida law, a PIP deductible cannot exceed $2,000.

PIP deductibles are not a good deal because it subtracts from the amount that the insurance company has to pay out of the $10,000 in benefits that you have available after an accident. In other words, a PIP deductible is self-insurance for that amount.

Therefore, if you have medical bills of $12,500 after an accident, instead of the insurance company paying $10,000 (leaving a balance of $2,500), your insurance company will pay $8,000 if you have a $2,000 deductible (leaving you with a $4,500 balance). Keep in mind that $12,500 is the minimum medical bill for which the full PIP limit can be reached. A PIP deductible usually doesn’t save you enough to have it.

What Is An Emergency Medical Condition And Why Is It Required?

Amendments to Florida’s no-fault law now require a person to have an EMC or emergency medical condition (section 627.732(16), Fla. Stat.) in order to qualify for the full $10,000 worth of benefits under a PIP policy. If you do not have an EMC or emergency medical condition, then your PIP benefits are limited to $2,500. This is a $7,500 difference!

The purpose of this distinction is to reduce or eliminate “soft tissue” injury cases. A soft tissue injury case is one in which there is pain and discomfort but no objective evidence of injury on an x-ray or an MRI.

Soft tissue cases are normally treated with chiropractic manipulation and palliative therapy. Insurance companies like to deny claims for soft tissue claims, however, the most common injury after a car accident is soft tissue. Consequently, these are also the most common cases that are litigated. You will likely need professional legal help to get fair compensation for a soft tissue injury case.

Permanent Injury Requirement

While Florida’s no-fault law is found in section 627.736, Fla. Stat., the so-called “permanent injury threshold” is found in section 627.737, Fla. Stat. Many people do not realize that the no-fault law operates as a “tort exemption.” This prevents you from suing the person who caused your accident unless you can prove at least one of the following in order to obtain damages beyond medical benefits provided in the no-fault law:

Significant and permanent loss of an important bodily function
Permanent injury within a reasonable degree of medical probability, other than scarring or disfigurement
Significant and permanent scarring or disfigurement
Death

If you can prove any of the following (this is often done by a doctor’s testimony that you have some degree of permanency with regard to your injuries), then you can obtain “pain and suffering” damages from a jury. If you cannot prove any of these items, then your claims are limited to the 20% that is generally not covered by PIP plus any medical expenses exceeding PIP and future medical expenses that are reasonably certain to occur.

PIP has become of the more complex areas of car accident litigation in Florida and its implications to your case may not be obvious.

Can I Save My PIP Benefits For Lost Wages?

Florida does allow you to reserve or apportion your PIP benefits for lost wages instead of paying medical bills. See Bennett v. State Farm Mut. Auto. Ins. Co., 580 So. 2d 217 (Fla. 2d DCA 1991). To do so, you need to notify your PIP carrier in writing of your request to apportion benefits toward wage losses instead of medical bills.

However, if you decide to notify your PIP carrier that you wish to reserve benefits for lost wages, you need to know that the insurance company may not respect your decision because there are essentially no consequences for not respecting your apportionment.

Under the decision in Northwoods Sports Medicine & Physical Rehabilitation, Inc. v. Daniel N., 137 So. 2d 1049 (Fla. 4th DCA 2014), any claim for PIP benefits is extinguished by the exhaustion of benefits, even after a PIP lawsuit has been filed.

Therefore, in combination with the $5,000 automatic reservation of PIP benefits for hospitals and ER’s during the first 30 days after an accident and the lack of teeth to an apportionment of benefits that you might make, your right to apportion the PIP benefits that you paid for may not be meaningful.