You were in a car accident. You followed the rules — you sought medical treatment within 14 days, you treated consistently, your doctors documented your injuries. Then your insurance company denied your Personal Injury Protection claim.
If that happened to you, you are not alone. PIP denials are common in Florida, and they are frequently wrong. Insurance companies have developed a sophisticated toolkit for reducing or eliminating PIP payments, and they use it aggressively. What they do not always tell you is that most of those denials can be challenged — and many of them can be beaten.
This post explains the most common reasons insurers deny PIP claims, how those tactics actually work, and how an attorney can step in to fight for the benefits you are entitled to under Florida law.
A Brief Primer on Florida PIP
Florida requires every driver to carry a minimum of $10,000 in Personal Injury Protection coverage. PIP is no-fault coverage, meaning it pays regardless of who caused the accident. It covers 80% of reasonable medical expenses and 60% of lost wages up to the policy limit.
The 14-day rule is critical: you must seek initial medical treatment within 14 days of the accident. If you do, and your treating physician documents an emergency medical condition (EMC), you are entitled to the full $10,000. If no EMC is established, coverage is capped at $2,500.
Simple enough on paper. In practice, insurers have built an entire industry around contesting these claims.
Independent Medical Examinations (IMEs)
The name is misleading. An Independent Medical Examination sounds like an objective second opinion. It is not.
Under Florida Statute § 627.736, insurers have the right to require you to submit to a physical examination by a physician of their choosing. In practice, insurers repeatedly use the same small pool of doctors — often referred to in plaintiff circles as “hired guns” — who examine claimants briefly and produce reports concluding that treatment is no longer necessary or was never necessary to begin with.
After an IME, the insurer will typically send a cutoff letter stating that benefits are being terminated as of the date of the examination. Everything billed after that date gets denied.
How we fight it: IME cutoffs are litigated constantly in Florida PIP cases. The insurer’s examining physician can be deposed. Their methodology can be challenged. Courts and arbitrators routinely look at the volume of work a particular IME doctor does for insurers, the brevity of their examinations, and the consistency with which they produce opinions favorable to the insurer. Your own treating physicians — who have actually followed your care over time — can provide competing opinions. A thorough IME report is not the end of your claim. It is the beginning of a fight.
Examinations Under Oath (EUOs)
An Examination Under Oath is a sworn statement the insurer can require you — and sometimes your medical providers — to give as a condition of processing your claim. Florida law permits EUOs as a post-loss obligation under the policy, and courts have generally enforced them.
The problem is how they are used. Insurers use EUOs as investigative tools to find inconsistencies, gaps, or admissions that justify denying the claim. Questions can cover the accident itself, your medical history, your treatment choices, your daily activities, and your finances. If the insurer decides your answers are inconsistent or that you failed to cooperate fully, they can deny the claim for breach of a policy condition.
How we fight it: An EUO is not an informal conversation — it is a sworn proceeding that can be used against you. No one should walk into an EUO without legal representation. As your attorney, I can prepare you, attend the EUO with you, object to improper questions, and ensure you do not inadvertently provide information that is used to build a denial. If the insurer uses an EUO denial pretextually — using minor inconsistencies as a pretext to deny an otherwise valid claim — that denial can be challenged in court.
Peer Reviews
A peer review is a paper review of your medical records conducted by a physician the insurer hires — often without ever examining you in person. The reviewing doctor analyzes your records and renders an opinion that certain treatment was not medically necessary, not related to the accident, or not consistent with the diagnosis.
The insurer then uses that peer review to deny or reduce payment on specific bills. Unlike an IME, there is no examination at all. The denial is based entirely on a doctor reading paperwork and concluding that your treating physician — who actually saw you — was wrong.
How we fight it: Peer reviews are among the most aggressively litigated issues in Florida PIP. The peer reviewer can be deposed. Their qualifications in the relevant specialty can be questioned. The adequacy of their review — whether they actually considered all relevant records — can be attacked. And your treating physician’s opinion, supported by examination findings and clinical notes, carries significant weight against a paper reviewer who never set eyes on you.
Material Misrepresentation on the Policy Application
This is one of the most serious denial grounds — and one of the most abused.
Under Florida law, an insurer can rescind an insurance policy if the applicant made a material misrepresentation on the application. A misrepresentation is “material” if it would have affected the insurer’s decision to issue the policy or the premium charged. Common examples insurers allege include failure to list all household members or regular drivers, incorrect address or garaging location, and prior accidents or claims not disclosed.
If the insurer successfully rescinds the policy, coverage disappears entirely — not just for your PIP claim, but retroactively. That is the nuclear option, and insurers know it.
How we fight it: Rescission based on material misrepresentation has strict legal requirements. The insurer must prove that the misrepresentation was made, that it was material, and that it was relied upon. Courts scrutinize these claims carefully. Many alleged misrepresentations are minor, inadvertent, or immaterial to the risk the insurer actually underwrote. In some cases, the insurer knew or should have known about the discrepancy and issued the policy anyway — which can defeat the rescission claim. This is a complex area of law where experienced representation is not a luxury, it is a necessity.
Other Common Denial Tactics
Beyond the big four, insurers employ a range of additional strategies to reduce or eliminate PIP payments:
Relatedness disputes. The insurer argues that your injuries were pre-existing or were not caused by the accident in question. Your medical history becomes a weapon. An experienced attorney anticipates this and works with treating physicians to ensure documentation clearly connects injuries to the accident.
Reasonableness of charges. Under Florida law, PIP pays the lesser of the provider’s charge or 200% of the Medicare fee schedule (or 80% of a reasonable amount, depending on the policy language selected). Insurers routinely contest whether charges are reasonable. This is a legitimate area of dispute, but it is also used as a blanket reduction tactic.
Emergency Medical Condition disputes. Reducing your available coverage from $10,000 to $2,500 by contesting the EMC determination is a low-cost, high-impact denial strategy. Insurers will use IMEs and peer reviews specifically to undermine the EMC finding that your treating physician made.
Late or incomplete billing. PIP claims must be submitted within 35 days of treatment. Insurers look for technical deficiencies in billing — missing codes, incorrect forms, procedural errors — to avoid payment. These deficiencies are often curable, but only if caught in time.
What Happens When You Sue
Florida’s PIP statute, § 627.736 and Florida Statute §86.121 includes a fee-shifting provision. If an insurer wrongfully denies PIP benefits and you prevail in litigation, the insurer can be required to pay your attorney’s fees and costs. This provision exists precisely to level the playing field and deter bad-faith denials.
It also means that in many PIP cases, the injured patient can be represented at no out-of-pocket cost — the insurer picks up the legal bill if you win.
This is not a technicality. It is the mechanism the Florida Legislature built into the PIP system to ensure that insurance companies cannot simply deny claims and wait out policyholders who cannot afford to fight back.
You Have Rights. Use Them.
A PIP denial letter is not the final word. It is a position taken by an insurance company that has a financial interest in paying you nothing. That position can be challenged, and in a significant percentage of cases, it should be.
If your PIP claim has been denied — for any reason — contact Licznerski Law, PLLC for a free consultation. I will review your denial, explain your options, and tell you honestly whether there is a case worth pursuing.
You paid for this coverage. You are entitled to it.
Contact Licznerski Law, PLLC
Serving injured patients throughout the Tampa Bay area and statewide.
Licznerski Law, PLLC | Oldsmar, Florida | 813-934-3519 | www.licznerskilaw.com
This post is for informational purposes only and does not constitute legal advice. Reading this blog does not create an attorney-client relationship.