In 2013, the Florida Legislature amended the No-Fault Act (Florida Statute 627.736) in an effort to curtail insurance fraud and reduce Personal Injury Protection (“PIP”) insurance premiums. One particular change is best described as the “14 day rule,” which mandates that an accident victim must seek initial services and care within 14 days after the motor vehicle accident to make a claim for medical benefits. F.S. 627.736(1)(a) The purpose of the statutory addition is to curtail claims being made out of sheer entitlement to pursue monetary compensation.
The legislative directive entailed within the “14 day rule” is, if you are really hurt, your natural bodily instincts will precipitate pursuit of initial services within 14 days. The unintended consequences of the new law could have negative monetary effects on medical providers, curtail claims from those injured in an accident who do not experience symptoms within 14 days and allow PIP insurers to accumulate higher rates while providing less coverage to their policyholders.
Unintended Consequences of the “14 Day Rule”
The new law sounds fair on its face, but the unintended consequences have hurt injured motorists, physicians, medical providers and non-insurance groups. Here are a few scenarios which illustrate the unintended consequences:
- EX1: Sam Driver is injured in a motor vehicle accident, he is experiencing back and neck pain but decides to self-medicate and wait out his 15 days later he leans over in the shower and the pain becomes unbearable, at which point he seeks treatment with a Chiropractor. THIS TREATMENT IS NOT COVERED THROUGH PIP BECAUSE THE TREATMENT WAS INITIATED OUTSIDE OF 14 DAYS.
- EX 2: Sam Driver’s Chiropractor treats Sam for 2 months and refers Sam out for 2 MRIs with a Radiologist. 65 days after Sam’s initial services, the Chiropractor and the Radiologist receive letters from Sam Driver’s PIP Insurer explaining that the treatment is being denied due to failure to seek treatment within 14 days. THIS TREATMENT IS NOT COVERED THROUGH PIP BECAUSE THE TREATMENT WAS INITIATED OUTSIDE OF 14 DAYS.
There are valid arguments on both sides of this issue but, insurance fraud and Florida PIP premiums continue to rise steadily. The amendment allows insurance companies to collect similar or higher rates while handling less claims.
For Sam Driver, his treating physician (in this case a chiropractor) must continue to treat him based on medical necessity and will eventually have to write off the bill and/or leave Sam Driver to pay for his treatment out of pocket. Florida Law requires each motorist to carry at least $10,000 in PIP coverage to pay for injuries related to a motor vehicle accident regardless of fault, therefore, the addition of the 14 day rule conflicts with underlying principles of “No-Fault” law.
Who Can Provide Initial Services Under the “14 Day Rule”
PIP Benefits are triggered “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 “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.”
When parsed out, subparagraph 1 is clear as to who can provide initial services:
- Physician (MD/DO)
- Emergency Medical Technician
- Hospital (and their staff)
- Nurse Practitioners
- Urgent Care
What is not clear, is what constitutes initial services. When a patient goes to a medical provider within 14 days and receives hands-on treatment, it is clear that initial services have been established.
Now for some unclear fact patterns:
- When a patient enters a medical provider’s office, fills out some paper work and leaves it is unclear whether their intent to initiate treatment is enough to satisfy the 14 day The statute does not make clear whether a doctor has to perform hands-on treatment to constitute initial services.
- When an individual is involved in a motor vehicle accident and is evaluated by an Emergency Medical Technician for potential injuries such as blood pressure, vitals, concussion, etc. This should constitute initial services, but it is commonly denied as a violation of the 14 day rule.
- When a patient initiates services with a massage therapist or acupuncturist, this does not constitute initial services.
- When a patient initiates services with a massage therapist or acupuncturist within 14 days and then also treats with a physician licensed under subparagraph 1 (above) within 14 days. This should constitute initial services, but some insurance companies will deny the claim.
The purpose of the 14 day rule conflicts with the general premise of the No-Fault Act. In most circumstances, whether the 14 day rule has been satisfied is clear, but when it’s not clear, you need to call the Horst Law Firm. Our truck accident attorneys have experience handling this issue. Our services are free, which includes review, demand, and litigation. When we win, the insurance companies pay our fees. If you have even an inkling of thought as to whether you were paid correctly, we are available to review past, present and future claims.