The new pip law has a requirement of finding and emergency medical condition in order for the payment of pip benefits beyond $2500.00
According to the new PIP statute, reimbursement is provided for services and care provided 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. Reimbursement for services and care provided is limited to $2,500 if any provider determines that the injured person did not have an emergency medical condition.
The new law defines emergency medical condition as follows: "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.
This definition, whether intentional or not, follows the United States code, which reads as follows: 42 U.S.C. § 1395dd(a) The Act defines an "emergency medical condition", in pertinent part, as (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in--(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part....
The courts have addressed the definition of emergency medical condition in numerous cases in the context of the Emergency Medical Treatment and Active Labor Act which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable medical condition. EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as "the COBRA law". EMTALA is Section 1867(a) of the Social Security Act, within the section of the U.S. Code which governs Medicare. EMTALA applies only to "participating hospitals" and the purpose of the statute is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to "charity hospitals" or "county hospitals" because they are unable to pay or are covered under the Medicare or Medicaid programs.
In the case of SCOTTSDALE HEALTHCARE, INC., v. Arizona Health Care Cost Containment System Nos. CV-02-0190-PR, CV-02-0218-PR, CV-02-0220-PR. Supreme Court of Arizona , August 20, 2003. The court identified symptoms manifesting an emergency medical condition, and found that they must not only have arisen rapidly, but more importantly, that they be short-lived.... [A] medical condition manifesting itself by chronic symptoms is not an emergency medical condition...."). To determine whether a patient suffers from an emergency medical condition the focus must be on the patient's current condition and whether that condition satisfies the criteria. The key term is "acute," which denotes that the symptoms manifesting an emergency medical condition must not only have arisen rapidly, but, more importantly, that they be short-lived. In other words, a medical condition manifesting itself by chronic symptoms is not an emergency medical condition, even though the absence of medical care might lead to one of the three adverse consequences listed the statute, "long-term" care was not contemplated by the statute. Nor does the statute limit the determination of when an emergency medical condition has ended to whether "the treating physician has a reasonable degree of confidence that the patient and his lay caregivers can manage his medical condition so that serious adverse consequences are not `reasonably likely' to occur," as urged by the hospitals. Instead, the focus must be on whether the patient's current medical condition—whether it is the initial injury that led to admission, a condition directly resulting from that injury, or a wholly separate condition—is a non-chronic condition presently manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical treatment could result in one of the three adverse consequences listed. If the resulting condition is manifested by chronic symptoms it is not an emergency medical condition. Whether a condition is manifested by acute symptoms or by chronic symptoms is a question of fact. See Mercy Healthcare, 181 Ariz. at 99, 887 P.2d at 629. As discussed above, it is neither practical nor possible to define with more precision when an emergency medical condition has ended. Rather, such determinations should largely be informed by the expertise of health care providers.
So what should we expect in Floirda as the new PIP law goes into effect? Will the new statute give insurance companies an easy out by the definition of emergency medical condition? This remains to be seen, stay tuned.
For more information or for a free consultation, contact Scott and Fenderson, PA Injury and Family Law Attorneys, by calling 727-321-0099 or view our web site www.scottandfenderson.com