Under a new statute that went into effect on January 1, 2013, PIP pays $2,500.00 in benefits, UNLESS there is a finding of an “emergency medical condition” which is referred to as an EMC. The statute gives a definition of an EMC. The definition of EMC, contained is 627.732(16) is shown below. Interestingly, the legislature, in Florida Statutes 627.736(1)(a)3. and 627.736(1)(a)4. a copy of which is below, lists the types of providers that are able to find an emergency medical condition as: 1) providers licensed under chapters 458 and 459 (physicians – medical doctors, M.D.s and osteopathic doctors, D.O.s), 2) dentists licensed under chapter 466, 3) physician assistants licensed under chapter 458 or chapter 459, or 4) advanced registered nurse practitioners licensed under chapter 464. Conspicuously missing from the list is Chiropractors, who treat a very large percentage of people injured in car accidents in my experience. Thus, if one were to solely treat with a chiropractor, PIP benefits would be limited to $2,500.00. This does not mean that people injured in accidents cannot treat with a chiropractor but in order to get the full $10,000.00 of medical benefits, one of the providers listed above (medical doctor, doctor of osteopathic medicine, dentist, advanced nurse practitioner or physician assistant; most commonly this would be a medical doctor) would have to find that the injured person has met the definition of an emergency medical condition or EMC. Further, someone could treat with a chiropractor before and/or after an emergency medical condition or EMC was found. The key is that in order to have $10,000.00 in medical benefits, at some point in the treatment with a chiropractor or other provider the injured person needs to have one of those enumerated medical providers, AND NOT A CHIROPRACTOR, find that they have an emergency medical condition, assuming the client has the emergency medical condition.
627.732 Definitions.—As used in ss. 627.730-627.7405, the term:
(16) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
(a) Serious jeopardy to patient health.
(b) Serious impairment to bodily functions.
(c) Serious dysfunction of any bodily organ or part.
627.736 Required personal injury protection benefits; exclusions; priority; claims.—
(1) REQUIRED BENEFITS.—An insurance policy complying with the security requirements of s. 627.733 must provide personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle, passengers in the motor vehicle, and other persons struck by the motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle, subject to subsection (2) and paragraph (4)(e), to a limit of $10,000 in medical and disability benefits and $5,000 in death benefits resulting from bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as follows:
(a) Medical benefits.—Eighty percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices and medically necessary ambulance, hospital, and nursing services if the individual receives initial services and care pursuant to subparagraph 1. within 14 days after the motor vehicle accident. The medical benefits provide reimbursement only for:
1. Initial services and care that are lawfully provided, supervised, ordered, or prescribed by a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, or a chiropractic physician licensed under chapter 460 or that are provided in a hospital or in a facility that owns, or is wholly owned by, a hospital. Initial services and care may also be provided by a person or entity licensed under part III of chapter 401 which provides emergency transportation and treatment.
2. Upon referral by a provider described in subparagraph 1., followup services and care consistent with the underlying medical diagnosis rendered pursuant to subparagraph 1. which may be provided, supervised, ordered, or prescribed only by a physician licensed under chapter 458 or chapter 459, a chiropractic physician licensed under chapter 460, a dentist licensed under chapter 466, or, to the extent permitted by applicable law and under the supervision of such physician, osteopathic physician, chiropractic physician, or dentist, by a physician assistant licensed under chapter 458 or chapter 459 or an advanced registered nurse practitioner licensed under chapter 464. Followup services and care may also be provided by any of the following persons or entities:
a. A hospital or ambulatory surgical center licensed under chapter 395.
b. An entity wholly owned by one or more physicians licensed under chapter 458 or chapter 459, chiropractic physicians licensed under chapter 460, or dentists licensed under chapter 466 or by such practitioners and the spouse, parent, child, or sibling of such practitioners.
c. An entity that owns or is wholly owned, directly or indirectly, by a hospital or hospitals.
d. A physical therapist licensed under chapter 486, based upon a referral by a provider described in this subparagraph.
e. A health care clinic licensed under part X of chapter 400 which is accredited by the Joint Commission on Accreditation of Healthcare Organizations, the American Osteopathic Association, the Commission on Accreditation of Rehabilitation Facilities, or the Accreditation Association for Ambulatory Health Care, Inc., or
(I) Has a medical director licensed under chapter 458, chapter 459, or chapter 460;
(II) Has been continuously licensed for more than 3 years or is a publicly traded corporation that issues securities traded on an exchange registered with the United States Securities and Exchange Commission as a national securities exchange; and
(III) Provides at least four of the following medical specialties:
(A) General medicine.
(B) Radiography.
(C) Orthopedic medicine.
(D) Physical medicine.
(E) Physical therapy.
(F) Physical rehabilitation.
(G) Prescribing or dispensing outpatient prescription medication.
(H) Laboratory services.
3. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. up to $10,000 if a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464 has determined that the injured person had an emergency medical condition.
4. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. is limited to $2,500 if any provider listed in subparagraph 1. or subparagraph 2. determines that the injured person did not have an emergency medical condition.
5. Medical benefits do not include massage as defined in s. 480.033 or acupuncture as defined in s. 457.102, regardless of the person, entity, or licensee providing massage or acupuncture, and a licensed massage therapist or licensed acupuncturist may not be reimbursed for medical benefits under this section.
6. The Financial Services Commission shall adopt by rule the form that must be used by an insurer and a health care provider specified in sub-subparagraph 2.b., sub-subparagraph 2.c., or sub-subparagraph 2.e. to document that the health care provider meets the criteria of this paragraph, which rule must include a requirement for a sworn statement or affidavit.
