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If you’re injured in a car accident in Florida, your Personal Injury Protection (PIP) benefits in your auto insurance policy will cover up to $2,500 or $10,000 in medical expenses. But shouldn’t your medical expenses be covered by your medical insurance, such that you receive through your workplace, or through Medicare or Medicaid? This is where coordination of benefits comes in. Coordination of benefits in health insurance and auto insurance policies decide which plan pays what, and in which cases. 

Note: Coordination of benefits differs across insurance companies, plans, states, and situations. Check with your insurance agent or your plan documents to get the details for your individual plan. 

Coordination of Benefits: Health Insurance vs PIP Insurance in Florida 

What is Coordination of Benefits in Health Insurance? 

Coordination of benefits in health insurance decides which plan pays when two or more policies conflict. The insurer who must pay first is named primary, any other insurer is secondary. Florida law clarifies coordination of benefits and coverage in many car accident cases, such as conflicting coverage for spouses, double coverage for children, or coverage for passengers in a car accident. However, coordination of benefits between an individual’s healthcare policy and PIP benefits is largely left to the contracts of each policy. 

To get the most out of your coverage and to make sure you receive the benefits that you pay for, it’s important to understand coordination of benefits between your health insurance and PIP benefits, as well as other policies like Med Pay benefits or workers’ compensation. You can find details on this in each policy’s coordination of benefits clause, or you can call your insurer. 

Is PIP Insurance or Health Insurance Primary in Florida?  

Though the rules for coordination of benefits between health insurance and PIP benefits vary between Florida and other states, in Florida PIP benefits are generally primary. Before your healthcare insurer will pay your medical bills, your PIP benefits must be exhausted. If you do not have an Emergency Medical Condition (EMC)—a life-threatening or debilitating injury—this will be $2,500, and $10,000 for an EMC. If your medical expenses exceed these amounts, your healthcare provider will then bill your healthcare insurer. 

Since PIP benefits are primary, your health insurer will need proof that you’ve exhausted your PIP benefits before they will provide benefits. This means if you have a conflict with your auto insurer providing PIP benefits, it can create additional problems with your medical insurance provider. PIP claim is denied, you may need to work with a lawyer. 

Is PIP Insurance or Workers’ Compensation Primary in Florida?  

If you’re in an auto accident while you’re working and you can be covered under workers’ compensation, coordination of benefits may involve your PIP benefits and a workers’ compensation case. Florida laws are unclear about which insurer is primary in this case. 

You should file both a PIP insurance claim and a workers’ compensation claim, though keep in mind you will not receive double benefits unless your reach a coverage limit. Your workers’ compensation case may ultimately reimburse your auto insurer, since PIP benefits are generally paid sooner. If your expenses exceed the amount you receive from workers’ compensation, PIP benefits may also take effect. 

What If My PIP Insurance Runs Out?

If your medical expenses exceed the $2,500 or $10,000 amount provided through PIP benefits, your healthcare provider should begin to bill your health insurer. Since the two are separate policies, different deductibles, percentages, total out-of-pocket maximums, and other payments will apply to each. This raises other questions about coordination of benefits between health insurance and PIP benefits, like how deductibles are covered (see below). 

Do PIP Payments Cover My Health Insurance Deductible? 

Most health insurance policies require a pre-set amount, your deductible, be paid before your health insurance will begin to pay. However, what if this amount was already paid, but by your PIP benefits instead of you? This coordination of benefits question between health insurance and PIP benefits becomes more complex. 

In some cases, it does not matter who paid the deductible amount, and your medical insurance will begin right away. In other cases, insurance companies claim PIP benefits cannot cover a deductible expenses, therefore you must pay it as you would with any other medical incident. This largely depends on your insurance carriers and the coordination of benefits clauses between your healthcare insurer and auto insurer. It’s best to ask your insurance providers these questions before you’re involved in an accident, so there is no confusion during an already stressful time. 

Can Health Insurance Cover What PIP Doesn’t? 

PIP benefits must cover at least 80% of your medical expenses. Does this mean your medical insurance can cover the other 20%? This again returns to coordination of benefits between your health insurance and PIP benefits. Your PIP benefits must be exhausted before your medical insurer will cover the costs, but they may at this stage cover what your PIP benefits didn’t, including this 20%. You should clarify this with your medical insurer, as each policy is different. 

Some drivers also have deductibles on their PIP benefits, similar to the deductible on their health insurance policies. If your expenses exceed your PIP benefits amount, your health insurance may cover your PIP deductible through coordination of benefits. 

Can Med Pay Cover What PIP Insurance Doesn’t? 

Med Pay is different from health insurance and different from PIP benefits. Med Pay is additional coverage you may select from your auto insurer to cover what PIP benefits do not. Since this is the purpose of Med Pay, it should cover, up to a pre-set amount, anything PIP benefits don’t, such as deductibles or the 20% co-insurance you pay. 

PIP covers unexpected services that Med Pay doesn’t. For example, Med Pay won’t cover lost wages, while many PIP insurance benefits will. Med Pay isn’t required in Florida; it’s coverage that is supplemental to PIP insurance. Med Pay shouldn’t be used to replace health insurance, since it has expense limits and can only be used in auto accidents. 

What if I Win a Lawsuit Against an At-Fault Driver?

Many drivers who are seriously injured file a personal injury lawsuit against an at-fault driver and win a financial settlement or judgement to cover their injuries or pain and suffering. Would this amount be paid to you, or to the insurance company that covered you? 

Coordination of benefits between your health insurance and PIP benefits no longer apply here. In this case, subrogation comes into effect. 

Subrogation is essentially a substitution in who is paid. In Florida, PIP benefits are not subject to subrogation. This means your auto insurer covers your medical expenses up to the set amount, and they won’t be reimbursed by the at-fault driver or their insurer. 

Keep in mind, different subrogation rules apply differently in other states and other situations. In Florida, subrogation works differently for Med Pay amounts, and different rules apply if a commercial vehicle was involved. When filing a personal injury lawsuit, work with a lawyer and inform them about all insurance parties involved to get a better idea of how subrogation works. 

Insurance coverage can be complicated, but knowing what you’re covered for and how to file a claim can drastically reduce the costs and stress of an auto accident. Regardless of your insurance situation, get treatment as soon as possible, and never forgo the procedures you need because you aren’t sure about your insurance. When you get treatment sooner, you’ll feel better and end up paying less in the long run.

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