The 14 Day Treatment Rule and how to handle it

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I have noticed recently an alarming high rate of PIP claims being denied by various insurance companies based on a patient not receiving treatment within 14 days of the date of the accident. It seems to me that insurance companies have a conference as to what their latest maneuver will be to deny claims and then all of a sudden you see different insurance companies denying claims for the same reason. So, let me remind you of the 14-day rule and how it works.

FS §627.736(1)(a) requires a patient to receive treatment, medical care or some type of initial services within 14 days of the accident as shown below: 

  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 S5.000 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:
    • 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. (Emphasis added).

The 14-day limitation has been challenged and courts have found the provision to be constitutional so we must live with the 14-day limitation. I find that the 14-day rule is a favorite for insurance companies to deny medical treatment as it is an easy rule for them to follow. Below is a list of “treatment” options by a patient that will satisfy the 14-day rule:

  1. EMS treatment at the scene of the accident;
  2. Transportation by an ambulance type service to a hospital;
  3. Treatment from any recognizable physician or nurse under the PIP statute;
  4.  Radiological testing of any sort recognizable under the PIP statute;
  5. Any other treatment payable under the PIP statute.

It makes no difference as to whether a medical provider submits a PIP claim for any medical treatment within 14 days, all that’s needed is that the patient treats within 14 days for accident-related injuries. As long as there is treatment recognizable under the PIP statute within 14 days, a PIP insurance carrier cannot properly deny a claim under FS §627.736(1)(a). Lazy or incompetent adjusters will not catch treatment that occurs within 14 days. I find that once an insurance company denies under the 14-day rule, they are stubborn to relinquish that denial.

So, how can medical providers work with the 14-day rule? Most medical providers will obtain a history of treatment that will include treatment within the first 14 days. It is important to also ask for EMS treatment at the scene, look at the police report to see if there was EMS treatment and see if there was transportation to a hospital. Patients can forget about or do not understand that EMS treatment at the scene constitutes treatment under FS §627.736(1)(a). Patients can also go to their family doctor first before seeing automobile accident healthcare specialists and forget about telling their specialists about those medical appointments. Medical providers should provide a comprehensive questioning to patients for a full history of their medical treatment. This practice not only helps in establishing medical treatment within 14 days but also helps in providing a medical provider with a full knowledge of a patient’s past medical treatment.