What qualifies as a catastrophic injury under Florida Law?

January 19, 2026

Dennis Hernandez

In Florida, a catastrophic injury usually means a person has long-term limits on their ability to live independently. This includes working and doing daily activities. Such injuries usually require long-term medical care and special equipment. Ongoing rehabilitation is also important. These factors must be included in any Florida catastrophic injury claim.

Common examples include:

Paralyzing spinal cord injury (complete or incomplete)

Severe traumatic brain injuries (TBIs)

Major limb amputations

Extensive burns over most of the body

Many fractures or crush injuries that interfere with strength and mobility

Although the phrase “catastrophic injury” is not present in every Florida Statute § 627.732(2) refers to “serious bodily injury” relative to insurance claims, and there are minimal differences between that definition and the ones listed above.

The damages of such injuries are not just physical but also monetary. Victims might need home improvements like ramps, lifts and accessible bathrooms. Adapted vehicles, specialized physical therapy and round-the-clock attendant care can quickly add up to millions of dollars in lifetime costs, all important factors for any catastrophic injury claim Florida.

The National Spinal Cord Injury Statistical Center reports that the average first year cost of such an injury is currently $1.1 million. Annual medical costs after that are frequently more than $200,000, and catastrophic injury cases are among the most expensive for the insurance industry.

Why Do Insurance Companies Try To Limit Coverage For Catastrophic Injuries?

Insurers are businesses. Big payouts for catastrophic injuries eat into such profit margins, so they frequently look for reasons to limit or deny claims.

One of the most popular forms is called insurance limits catastrophic injury Florida provisions. These are the maximum amount that an insurer will pay, no matter what is actually spent. If your care is worth more, you are left to pick up the cost unless there is someone else who can be chased up.

Other tactics include:

Contending that continued care is not “medically necessary.”

Necessitating many independent medical examinations (IMEs) in order to obtain contradictory reports

Slow-walking approvals for treatment or equipment

Paying off early on the cheap to avoid being forced into future settlements

The plan is simple: spare yourself financial exposure – regardless of the harmed person’s recovery and lifestyle.

How Can Reviewing Your Policy Help Protect Your Rights?

Your insurance policy is a contract, and every word counts. Seeing through it is the first to fighting back. Start by reading sections on:

Bodily injury coverage
Medical payments (MedPay)
Exclusions and limitations

Watch out for ambiguous expressions. Because of that standard, Florida courts usually give the benefit of any doubt to the insured. See State Farm Fire & Casualty Co. v. Castillo, 829 So. 2d 1261 (Fla. 3d DCA 2000), the Court reemphasized that undefined terms are to be interpreted in favor of policyholders.

This rule is very important to use when fighting a denied high-cost injury claim as this can be the difference between full coverage and partial payment.

A personal injury lawyer can review your policy with you and help to clarify your rights, as well as the circumstances under which an insurance company may be acting in bad faith.

What Documentation Should You Gather To Strengthen Your Claim?

And when insurers decide whether they will pay, restrict or deny a claim, they very much depend on documentation. Your objective is to write a file so comprehensive that there’s little scope for doubt.

Essential documents include:

A full medical release, including test results and letters from doctors

Contemporaneous specialist consultation notes and treatment plans

Bills from hospitals, rehab centers and medical equipment providers

Proof of home improvements and accessibility features

Written correspondence with your insurer

Expert opinions from independent specialists indicating treatment cannot possibly be delayed

Florida Rule of Civil Procedure 1.280 allows for liberal discovery in the course of litigation. If your case goes that far, this rule permits your lawyers to request the insurance company’s internal records, like claim review notes, which could expose wrongful denials.

When Should You Contact A Personal Injury Attorney?

There is no need to wait until your claim is formally denied before getting legal representation. Disputes are often nipped in the bud with early intervention.

An experienced personal injury lawyer can:

Look over your policy and find coverage holes

Verify patient has all necessary medical records that insurer requires

Guide you on the communications so you don’t accidentally hurt your case

Your lawyer will hire expert witnesses to support your case

At Dennis Hernandez Injury Attorneys, we have won millions and millions for clients. We understand the tricks of the insurers and fight to keep them in check at every turn. We fight to get you paid!

If your insurance provider is slow to authorize a surgery, rehabilitation or medical devices – it may take even longer without legal representation and you could potentially lose some of what’s rightfully yours after suffering.

How Does The Appeals Process Work For A Denied Catastrophic Injury Claim?

Almost all insurance policies include an internal appeals process that allows you to fight a denial before filing suit. This process typically involves:

Scrutinizing the denial for detail

Assembling Contemporary Medical Evidence and Expert Opinion

Drafting a letter appealing each of the concerns stated by the insurance party

Filing the appeal within the insurer’s tight deadline, sometimes 30 to 60 days

Under Fla. Stat. § 627.736, insurers that issue personal injury protection (PIP) coverage are required to pay covered benefits promptly. If your denial is due to medical necessity, you will need a well crafted treating physician opinion can be the spice that tips the scale.

The U.S. Department of Labor reports that claimants who petition for reconsideration are statistically more likely to have your approval at some level than those who roll over on the insurer’s initial determination.

What Happens If Your Appeal Is Still Denied?

If appeal does not work, you can sue. This means filing a breach of contract suit and in some cases, a bad faith action pursuant to Fla. Stat. § 624.155.

An insurance company acts in bad faith when it unreasonably denies benefits, doesn’t conduct a reasonable investigation, or ignores the chance to settle for policy limits.

In Boston Old Colony Insurance Co. vs. Gutierrez, 386 So. 2d 783 (Fla.1980), the Supreme Court of Florida held that insurance companies owe a duty of good faith to their insureds to protect insureds from judgments in excess of liability policy limits.

It takes time to litigate. However, the prospect of a judgment for an amount beyond policy limits will usually pressure insurers to fairly settle cases.

Are Mediation Or Arbitration Viable Alternatives To Court?

Yes. Alternative dispute resolution, mediation and arbitration enables quicker, cheaper resolutions to most disputes than full-blown litigation.

Mediation: The two sides sit down with a neutral mediator to talk about possible settlements.

Arbitration: A kind of private judge who hear both sides and makes a decision; the arbitration can be binding or non-binding, depending on what they all agree when they sign up.

These methods can be a particularly powerful tool in catastrophic injury disputes where securing medical care is time-sensitive. But agreeing to binding arbitration without the counsel of a lawyer can box you out future options.

What Time Limits Apply To Catastrophic Injury Insurance Disputes?

Florida’s five-year statute of limitations for breach-of-contract suits, including disputes about insurance coverage, is set forth in Fla. Stat. § 95.11. But for internal policy deadlines on appeals are much sooner.

Missing them can result in losing your rights, even if you should have a legitimate claim. The best option is to just take a quick action right after you’ve gotten the boot.

How Can State-Specific Laws Affect Your Insurance Dispute?

Florida laws regarding insurance contain many deadlines and requirements imposed upon insurers. For example, Fla. Stat. PIP insurers must make such payments for benefits within 30 days of receiving written notice that loss is covered.

If your delayed payment is unreasonable, some extra claim theory may apply in addition to the original claim for benefits.

Can Real-Life Examples Show How To Fight Back Against Insurers?

Think of a Florida teacher who suffered a traumatic brain injury (TBI) in a highway crash. Her insurance company refused to cover the specialized neurorehabilitation she needed, claiming it was experimental. The lawyer provided research from peer-reviewed journals demonstrating the therapy’s effectiveness, along with testimony from her neurologist. This prompted the insurance company to do an about-face, saving her family over $350,000 in out-of-pocket costs, a successful catastrophic injury claim in Florida.

Or the situation of a warehouseman who had lost his leg and needed to upgrade his prosthetic limb every five years. His insurer would pay for one device at first. Litigation showed that the policy lined up on the side of replacements, which translated to a lifetime prosthetics benefit of more than $600,000, an example of catastrophic loss claims Florida.