Florida PIP: the 14-day rule and 80/60 split

PIP questions are arithmetic wrapped around two gates. First gate: was the injured person seen within 14 days? Miss it and the medical benefit is gone entirely, not reduced. Second gate: did a qualified provider determine an emergency medical condition? Miss that and the $10,000 limit collapses to $2,500. Only then do the percentages matter.

Questions and answers, explained

All 10 questions above, with the correct answer and why it is correct. Everything here is on florida pip: the 14-day rule and 80/60 split.

1. Hurricane storm surge submerges a Cape Coral insured's parked car. Her homeowners policy excludes flood. Her personal auto policy carries liability, PIP, other than collision and collision. How does the auto policy treat the damage to the car?

   • AIt is excluded, because flood is excluded under every property and auto form alike
   • BIt is paid under Collision coverage, because moving water displaced the vehicle
   • CIt is paid under Other Than Collision coverageCorrect
   • DIt is paid only if she also carries a separate flood policy listing the vehicle

   Why: Flood and water damage to an automobile is an Other Than Collision loss under the personal auto policy, which expressly lists flood among the perils treated as other than collision. This is a frequent Florida exam point: the homeowners form excludes flood but the auto form covers it under comprehensive, so a separate flood policy is neither available nor needed for the vehicle. Collision means impact with another object or upset, not immersion.

   Reference ISO PP 00 01, Part D – Coverage for Damage to Your Auto

2. A Florida clinic's personal injury protection claim is overdue. It mails the insurer a presuit demand letter under s. 627.736 by certified mail. Twenty-two days later the insurer pays the overdue amount with interest and the statutory penalty. What is the effect?

   • ASuit may still be filed, because the statutory penalty is 10 percent with no dollar cap
   • BNo action may be brought on that claim; the penalty is 10 percent, capped at $250Correct
   • CNo action may be brought, but only if payment is made within 10 business days of the letter
   • DSuit may still be filed unless the insurer also pays the clinic's presuit attorney fees

   Why: Section 627.736(10), F.S., makes a written presuit demand letter a condition precedent to a PIP suit. The notice may not be sent until the claim is overdue, and if within 30 days after receipt the insurer pays the overdue claim with applicable interest plus a penalty of 10 percent of the overdue amount, subject to a maximum penalty of $250, no action may be brought on that claim. Twenty-two days is inside the window. Option C is the tempting figure: 10 business days is not the PIP demand-letter period.

   Reference s. 627.736(10), F.S.

3. A Florida driver is injured in a crash on May 1. Feeling only stiffness at first, she seeks no care until she is examined by a licensed chiropractic physician on May 20. She then submits the bills to her PIP carrier. What is the result?

   • APIP pays 80 percent of the reasonable expenses, because treatment began within 30 days of the crash
   • BPIP pays nothing toward those medical expenses, because her initial care was not timelyCorrect
   • CPIP pays, but reimbursement is capped at $2,500 because a chiropractic physician provided the care
   • DPIP pays in full, because the 14-day rule governs follow-up care rather than initial treatment

   Why: Section 627.736(1)(a), F.S., conditions PIP medical benefits on the initial services and care being lawfully provided, supervised, ordered, or prescribed within 14 days after the motor vehicle accident. Treatment first sought on day 19 falls outside that window, so the medical benefit is lost regardless of how reasonable or related the expenses are. The provider type was not the problem: a chiropractic physician licensed under chapter 460 may render qualifying initial services, alongside physicians under chapters 458 and 459, dentists under chapter 466, advanced practice registered nurses, hospitals and facilities, and licensed emergency transportation and treatment providers. The $2,500 sublimit in option C is real but attaches when a qualified provider determines the injured person did not have an emergency medical condition, not to the provider's license type.

   Reference s. 627.736(1)(a), F.S.

4. A Sarasota driver is injured in a crash on 2 March. She first seeks treatment on 20 March, eighteen days after the crash, from a chiropractic physician licensed under chapter 460. Under the Florida Motor Vehicle No-Fault Law, her PIP medical benefits are:

   • APayable in full, up to the $10,000 combined medical and disability limit
   • BNot payable, because she was not seen within 14 days after the crashCorrect
   • CLimited to $2,500, because the initial provider was a chiropractic physician
   • DPayable at 60 percent rather than 80 percent because treatment was delayed beyond 14 days

   Why: Section 627.736(1)(a), F.S., conditions PIP medical benefits on the injured person receiving initial services and care within 14 days after the motor vehicle accident. Missing that 14-day window forfeits PIP medical benefits altogether rather than merely reducing them. A chiropractic physician licensed under chapter 460 is one of the providers who may lawfully render the initial services — alongside a physician under chapter 458 or 459, a dentist under chapter 466, an advanced practice registered nurse registered under s. 464.0123, and hospitals or hospital-owned facilities — so the timing, not the profession, is what defeats this claim. Note the related trap: a chiropractic physician may render initial care but may not determine an emergency medical condition, so chiropractic-only treatment would have capped reimbursement at $2,500 even if she had been seen inside the 14 days. The 60 percent figure applies to loss of gross income, not to medical bills.

   Reference s. 627.736(1)(a), F.S. (14-day initial services and care; providers who may render it; providers who may determine an emergency medical condition)

5. On March 1 a medical provider furnishes a PIP insurer with written notice of a covered loss and the amount owed. The insurer has paid nothing by April 15 and the provider wants to sue. Under s. 627.736, F.S., what is the provider's position?

   • AThe benefits are overdue, and suit may be filed at once with no further notice
   • BThe benefits are not yet overdue, because the insurer has 60 days to pay them
   • CThe benefits are overdue, and a presuit demand letter is required before suitCorrect
   • DThe benefits are not overdue until DFS issues a written notice of violation

   Why: Two rules combine here. Section 627.736(4)(b), F.S., makes PIP benefits overdue if they are not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss and the amount of it, so April 15 is well past due and simple interest under s. 55.03, F.S., is running. But s. 627.736(10), F.S., separately requires a written presuit demand letter, identified as a demand letter under s. 627.736, as a condition precedent to filing any action for PIP benefits. Option A is the natural but wrong conclusion: overdue does not mean immediately suable. The insurer then has 30 days after receiving the demand to pay the overdue amount plus interest and a 10 percent penalty capped at $250, and if it does, no action may be brought.

   Reference s. 627.736(4)(b) and (10), F.S.

6. A Miami passenger is treated at an urgent care center five days after a crash, well inside the statutory window. No physician, osteopathic physician, dentist, physician assistant or advanced practice registered nurse ever determines that she suffered an emergency medical condition. Her reasonable medical bills total $9,000. What is the most her PIP medical benefits will pay?

   • A$10,000
   • B$7,200, being 80 percent of $9,000
   • C$5,000
   • D$2,500Correct

   Why: Florida PIP reimburses medical services up to $10,000 only where a qualified provider has affirmatively determined that the injured person had an emergency medical condition. Where no such determination is made, s. 627.736(1)(a), F.S., leaves reimbursement at the $2,500 level, and insurers apply that cap. The 80 percent reimbursement rate still operates inside that cap, but the cap is the binding constraint, so $7,200 is not payable. The $5,000 figure is the separate PIP death benefit, which is in addition to medical and disability benefits, not a medical sublimit.

   Reference s. 627.736(1)(a), F.S. (emergency medical condition; $2,500 limit)

7. A Florida insured is injured in a crash and receives initial treatment within 14 days. A qualified provider documents an emergency medical condition. What does her personal injury protection coverage pay?

   • A100 percent of medical expenses and 80 percent of lost income, up to $10,000
   • B80 percent of medical expenses and 100 percent of lost income, up to $2,500
   • C60 percent of medical expenses and 80 percent of lost income, up to $15,000
   • D80 percent of medical expenses and 60 percent of lost income, up to $10,000 totalCorrect

   Why: Section 627.736(1), F.S., sets PIP benefits at 80 percent of reasonable and medically necessary medical expenses, 60 percent of loss of gross income and loss of earning capacity, all reasonable expenses for replacement services, and a death benefit of $5,000 per individual. The medical and disability benefits share a single $10,000 aggregate limit when a physician, dentist, physician assistant, or advanced practice registered nurse determines that the injured person had an emergency medical condition. Option B is the strongest distractor because $2,500 is a real Florida figure — it is the reduced medical limit that applies when a qualified provider determines there was no emergency medical condition — and because candidates routinely flip the 80 and 60 percent figures between the medical and wage benefits.

   Reference s. 627.736(1), F.S.

8. A Florida insured with standard PIP is determined by a qualified provider to have an emergency medical condition. She incurs $4,000 of reasonable medical expenses and loses $3,000 of gross income while unable to work. Her policy carries no PIP deductible. What will PIP pay?

   • A$7,000 — 100 percent of both amounts
   • B$4,000 medical and $1,800 disability, for $5,800 total
   • C$3,200 medical and $1,800 disability, for $5,000 totalCorrect
   • D$3,200 medical and $3,000 disability, for $6,200 total

   Why: Florida PIP pays 80 percent of reasonable medical expenses and 60 percent of loss of gross income and loss of earning capacity, all within a combined $10,000 limit. Eighty percent of $4,000 is $3,200 and 60 percent of $3,000 is $1,800, giving $5,000 in total, comfortably inside the limit. Replacement services are the item paid at 100 percent of expenses reasonably incurred, and the $5,000 death benefit is separate and in addition to medical and disability benefits.

   Reference s. 627.736(1)(a)–(c), F.S.

9. A Florida PIP insured is examined within 14 days of a crash and a licensed physician determines she had an emergency medical condition. Which statement about her personal injury protection benefits is correct?

   • AMedical benefits are 80 percent of expenses, under the combined $10,000 limitCorrect
   • BMedical benefits are 100 percent of reasonable expenses, up to a $10,000 cap
   • CDisability benefits replace 80 percent of her lost gross income while recovering
   • DMassage therapy is reimbursable whenever a licensed physician prescribes it

   Why: Section 627.736(1)(a), F.S., sets PIP medical benefits at 80 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. Read that against the flush language of s. 627.736(1), which fixes the limit at $10,000 in medical AND disability benefits and $5,000 in death benefits. The $10,000 is one shared pot, not a medical-only cap: every dollar of wage-loss benefit paid erodes what is left for medical bills, while the $5,000 death benefit sits outside the $10,000 entirely. The full $10,000 becomes available only once a qualified provider determines the injured person had an emergency medical condition; if a provider instead determines there was no emergency medical condition, medical reimbursement is capped at $2,500. Option C is the strongest distractor because the two percentages are constantly swapped: disability benefits under (1)(b) are 60 percent of any loss of gross income and loss of earning capacity, not 80 percent. Massage therapy and acupuncture are excluded from PIP reimbursement regardless of who renders or prescribes them, so D is wrong.

   Reference s. 627.736(1) and (1)(a), F.S.

10. A new Florida resident is registering a private passenger automobile with four or more wheels. Which minimum coverages must she show to satisfy Florida's compulsory requirements at registration?

    • A$10,000 personal injury protection and $10,000 property damage liabilityCorrect
    • B$10,000 personal injury protection and $10,000/$20,000 bodily injury liability
    • C$10,000/$20,000 bodily injury liability and $10,000 property damage liability
    • D$5,000 personal injury protection and $25,000 of property damage liability

    Why: Florida compels only two coverages at registration for an ordinary private passenger car: $10,000 of personal injury protection under the No-Fault Law and $10,000 of property damage liability under s. 324.022, F.S. Bodily injury liability is not compulsory at registration for such a vehicle. The $10,000 per person and $20,000 per crash figures in s. 324.021(7), F.S., are the proof-of-financial-responsibility limits, which bite only when a driver is required to file proof, for example after certain crashes or convictions. Section 324.022(1), F.S., also lets an owner satisfy the property damage requirement with a combined bodily injury and property damage single limit of at least $30,000, but the $10,000 property damage figure is the baseline the question asks for.

    Reference s. 627.733(1) and (3)(a), F.S. (PIP required as security at registration); s. 627.736(1), F.S. ($10,000 PIP benefit); s. 324.022(1), F.S. ($10,000 property damage, or a $30,000 combined single limit); s. 324.021(7), F.S. (proof-of-financial-responsibility limits)

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