Florida’s Fifth District Court of Appeal Reveals Evolving Case Law for PIP Payments


Florida’s Personal Injury Protection laws have undergone a lot of changes in recent years.  Now treating doctors and clinicians must meet guidelines set by the Florida legislature before PIP payments are issued.  Accident injuries must also meet statutorily created criteria before the full $10,000 will be issued for “serious injuries”.  Now a series of appellate decisions from Florida’s Fifth District Court of Appeals covers another issue with PIP payments: whether or not medical groups providing emergency care must wait until the deductible is met before it receives payment, even though it was elected by the insured. 

Florida Statute 627.736 mandates that insurance companies keep a reserve of $5000 for payment of bills from emergency providers.  It also states that the deductible amount must be applied to 100 percent of the expenses.  Recently, the district appellate court ruled in favor of an insurance company seeking a certiorari review of a circuit court summary judgment allowing payment to an emergency physicians group.  In its opinion reversing the circuit court’s summary judgment, the court referred to two Fifth District decisions issued last year, Mercury Insurance Co. of Florida v. Emergency Physicians of Central Florida, (Case No. 5D15-1064 ), and Metropolitan Casualty Insurance Co. v. Emergency Physicians of Central Florida, LLP, 178 So. 3d 927 (Fla. 5th DCA 2015). 

In the Mercury Insurance Co. case, the insured was involved in a car accident.  She sought treatment from an emergency room, which sent a bill for $191 to her insurer for her treatment.  The injured women’s policy provided $10,000 in PIP benefits with a $500 deductible.  The bill was applied to the injured woman’s deductible, but not paid by the insurer to the emergency room group since it was the only bill received within the first 30 days after the accident and the deductible was not met by other bills for another couple of months.  The emergency room group sued for payment from the insurer, which argued that it did the right thing by applying the bill to the insured’s deductible.  The group disagreed, pointing to Florida statute 627.736, which requires $5000 to be set aside for emergency rooms, and argued that deductibles were not supposed to be considered.

The district appellate court agreed with the insurance company’s argument that the Florida legislature did not intend for the emergency room reserve to be free from the application of deductibles.  In its reading of Florida Statute 627.739(2), the court pointed to the plain language of the statute which specifically exempted death benefits from contracted deductibles.  The court felt that the legislature would have done the same thing if it intended for emergency rooms to be treated in a similar manner.  The appellate court reversed the circuit court’s determination in Mercury favoring the emergency room group, and continues to uphold this assessment in follow-up cases. 

Navigating insurance payments can become complicated, and it helps to have experience Florida car accident attorneys at your side.  For a free, confidential consultation, contact the attorneys at Donaldson & Weston at 772-266-5555 or 561-299-3999. 

More Blog Posts:

Florida Appellate Court Reinstates Injured Automobile Passenger Award of Over $93,000, South Florida Injury Lawyer Blog, February 17, 2016

Florida’s First District Court of Appeal Allows Child’s Wrongful Death Suit to Continue, South Florida Injury Lawyer Blog, January 18, 2016