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Thursday, January 30, 2014



Dr. Alan Himmel

Just as predicted, there are some companies who are ignoring Emergency Medical Conditions and denying PIP coverage beyond $2500.   So, a medical provider, in many cases a specialist, will look at and examine a patient, and say, "Yes, without medical treatment, this patient is likely going to suffer long term permanent impairments,"  and write it exactly as the law is written, and certain insurance companies are having the doctor's notes and records reviewed by one of their doctors to say that its not true.

I just had a patient with an shoulder impingement syndrome denied.  The patient cannot raise her arm up past 90 degrees in any direction.  She cannot take a half gallon of milk out of the fridge due to pain and weakness in her shoulder, and an insurance company doctor says she needs no further treatment. The MRI alone was more than half her PIP benefit.

Surprisingly, this denial is happening with major providers.  You would think that the small rip-off companies would be doing this, but as I said, even the big boys are doing it.

So, what do you do?  As a doctor who spends a lot of time with patients one on one (sometimes more than an hour), I have to make a decision.  The decision is whether to release the patient from care, or to continue treating in the hopes that in the end, a suit can be filed, and the insurance company will eventually pay.  SInce this whole EMC thing is a new thing in Florida, there are a lot of unknowns.

The first unknown is whether a suit can be won in the first place.  Lawyers cannot guarantee a win. And, as I said, this is a new program in FL, so there is not a whole lot of new case law.   Secondly, if a suit is won, will the WHOLE bill be paid, or will only part of it be paid?  What if a Judge says, pay the bill, but only 20% of it?  Can they do that?  A colleague of mine seems to think so.  He may be right.

My patient with shoulder impingement I am continuing to see and treat.  She is doing better and better. Without treatment her condition would likely turn into frozen shoulder.