18 Fla. L. Weekly Supp. 480b
Online Reference: FLWSUPP 1805GARR
Insurance — Personal injury protection — Deductible — No merit to insurer’s claim that insured was required to pay bills received from other medical providers and applied to deductible before insurer’s obligation to pay plaintiff medical provider’s bills in excess of deductible would ripen — Insurer is obligated to pay amount of medical provider’s bills less remainder of deductible
DR. GARRETT R. WEINSTEIN, D.C., P.A. a/a/o DEVONTE ST. LOUIS, Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-008109 COCE 51. March 11, 2011. Martin R. Dishowitz, Judge. Counsel: Marc Finkelstein, Law Offices of Marc Finkelstein, P.A., Fort Lauderdale, for Plaintiff. Justin Cincola, Miami, for Defendant.
FINAL SUMMARY JUDGMENT FOR PLAINTIFF
THIS CAUSE came to be heard on February 23, 2011 upon the Plaintiff’s Motion for Final Summary Judgment as well as the Defendant’s Motion for Final Summary Judgment regarding the bills applied to deductible. The Court, having heard argument of both Plaintiff’s and Defendant’s counsel, reviewed the applicable case law and being duly advised in premises, finds and decides as follows:
FINDINGS OF FACT
This lawsuit arises out of the denial of Personal Injury Protection (“PIP”) benefits to DR. GARRETT WEINSTEIN, D.C., P.A., (hereinafter “Plaintiff”) for treatment and services rendered to Devonte St. Louis, an insured of the Defendant, UNITED AUTOMOBILE INSURANCE COMPANY (hereinafter “UNITED”). Plaintiff timely submitted its claims to the Defendant in the amount of $2,185.00. Defendant failed to pay the Plaintiff’s claims.
Plaintiff subsequently filed a complaint for breach of contract seeking payment in the amount of $1,748.00 (eighty percent of the total amount billed). Defendant served its Answer and Affirmative defenses alleging that the insurance policy included a $2,000.00 deductible, whereby the policyholder and/or claimant, contractually agreed to be financially responsible for the first $2,000.00 in medical services, treatments, and/or PIP benefits in the event of a loss that occurs within the policy period. Defendant further stated in its affirmative defense, that the Plaintiff’s bills for medical services would be applied towards this claimant’s deductible.
The parties stipulated that the only remaining issue was whether or not all of the Plaintiff’s bills would be applied to the claimant’s deductible. Plaintiff’s motion for final summary judgment alleged that the first two bills received by UNITED, Sheridan’s Children’s Health and Plantation General Hospital were applied to a portion of the claimant’s deductible. In support of Plaintiff’s motion, Plaintiff relied on the deposition testimony of United’s litigation adjuster, Mercedes Serrano.
Defendant’s initial motion for final summary judgment alleged that the bills from Sheridan’s Children’s Health and Plantation General Hospital were not paid and were not applied to the Claimant’s deductible. Defendant subsequently filed its amended motion for final summary judgment, amending its previous averments to assert that the bills from Sheridan’s Children’s Health and Plantation General Hospital: “[i]nitially, Defendant allocated the responsibility to pay the bills for Sheridan’s Children’s Health and Plantation General Hospital bills to Devonte St. Louis as they would be applied to the deductible in the subject insurance policy. . .” United expected its insured to pay the deductible of $2,000, pursuant to the terms and conditions of the insurance policy and relied upon the insured to perform its duty to pay its deductible. . . “[a]fter the Statute of Limitations ran on the bills. . .United conducted an investigation as to whether the insured, Devonte St. Louis, paid his deductible for the claim. . . . and found out that these bills were never paid.” In support of Defendant’s motion, Defendant relied upon the affidavit of Ismail Sarabi.
Devonte St. Louis was involved in a motor vehicle accident on July 6, 2003. As a result of the automobile accident, Devonte St. Louis incurred reasonable medical expenses from Plantation General Hospital and Sheridan Children’s Health. The policy of insurance contained a $2,000.00 deductible. Defendant’s litigation adjuster, Mercedes Serrano, testified in her deposition on March 5, 2008, that the bills from Sheridan Children’s Health and Plantation General Hospital were applied to the claimant’s $2,000.00 deductible. Pursuant to the deposition testimony of Mercedes Serrano as well as the No Fault Payment Log entered into evidence at the time of Ms. Serrano’s deposition, Sheridan Children’s Health was the first claim received by United. That bill, which totaled $287.00, was the first bill applied towards the claimant’s $2,000.00 deductible as follows: $287.00 multiplied by .80 = $229.60; $2,000.00 – $229.60 = ($1,770.40), the remaining deductible.
Ms. Serrano further testified that the second claim received by UNITED was from Plantation General Hospital. That bill, which totaled $1,022.00 was also applied towards the claimant’s remaining deductible ($1,770.40) as follows: $1,022.00 multiplied by .80 = $817.60; $1,770.40 – $817.60 = ($952.80) as the remaining deductible.
Ms. Serrano also testified that the next set of bills received by UNITED, was that of the Plaintiff’s, which totaled $2,185.00. The Plaintiff’s bills exceeded the remaining deductible. UNITED conceded that the Plaintiff’s bills were reasonable, related and necessary. Accordingly, these bills would be applied as follows: $2,185.00 x .80 = $1,748.00. After applying the remaining deductible: $1,748.00 – $952.80 = $795.20. UNITED became obligated to pay 80% of all reasonable and necessary medical expenses which were related to the automobile accident once the deductible was met.
CONCLUSIONS OF LAW
Pursuant to Fla. Stat. §627.736(1) “Every insurance policy complying with the security requirements of s. 627.733 shall provide personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle. . .to the limit of $10,000 for loss sustained by any such person as a result of bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as follows: (1)(a) Eighty 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. . . .” (emphasis added)
Since the policy of insurance contained a $2,000.00 deductible, the claimant would be responsible for the first $2,000.00 of medical bills before United would be obligated to pay any claim. However, once that deductible has been met, the statutory amount would then become applicable and United would be obligated to pay 80% of the reasonable and necessary medical expenses which were related to the automobile accident. A deductible is a clause in an insurance policy that relieves the insurer of responsibility for an initial, specified loss of the kind insured against. General Star Indem. Co. v. West Florida Village Inn, Inc., 874 So. 2d 26, 33 (Fla. 2d DCA 2004) [29 Fla. L. Weekly D1070b]. It is subtracted from the statutory mandated PIP coverage limit of $10,000.00. International Bankers Ins. Co. v. Arnone, 552 So. 2d 908, 911 (Fla. 1989). Therefore, subject to the limitation that an insurer’s exposure is limited to the statutory coverage limits of $10,000.00, those medical bills which were received first, are to be applied to the deductible when received and an insurer’s obligation to pay benefits does not begin until after the deductible is exceeded.
Pursuant to Florida Statute 627.736 and the policy of insurance at issue, the bills received from Sheridan Children’s Health and Plantation General Hospital, the total of which is $1,309.00, were correctly applied to the Claimant’s deductible. When properly applied, the remaining deductible was $952.801.
UNITED claimed that after the statute of limitations ran on the first two bills received, UNITED conducted an investigation which revealed that the claimant did not pay said bills. UNITED argues that the claimant/insured had a duty to pay these two bills pursuant to the policy of insurance before UNITED’s obligation to pay any claims would ripen. UNITED further argued that because the insured (allegedly) did not pay his deductible, the statute of limitations had run on those claims, and neither Sheridan Children’s Health nor Plantation General Hospital filed a lawsuit against UNITED, that UNITED was no longer required to apply those bills to the claimant’s deductible, and since those bills were not paid within thirty (30) days, the bills were automatically considered denied, thereby requiring UNITED to subsequently move up the Plaintiff’s bills and apply them to the claimant’s deductible2. To support this argument, United relied on the opinion in the case of United Automobile Insurance Company v. Florida Orthopaedic Center as assignee of Alexis Gonzalez, 16 Fla. L. Weekly Supp. 402a (17th Jud. Cir. App. 2009), wherein the Court opined that “the medical provider who was first-in-time lost its place when the insurance company denied their claim. . .”
This Court finds that the facts in the Gonzalez case are distinguishable to this case in that the Gonzalez case involved medical bills that were denied, whereas this case involves medical bills that were never denied and were applied to the claimant’s deductible3. Additionally, had either Sheridan Children’s Health or Plantation General Hospital elected to sue UNITED for payment of their bills, either lawsuit would have been dismissed since the total of both bills were far less than the $2,000.00 deductible. See Digital Medical Diagnostics a/a/o Jesus Gaber v. United Automobile Insurance Company, 958 So.2d 505 (Fla. 3rd DCA 2007) [32 Fla. L. Weekly D1392a].
Moreover, this Court finds that there is no provision in Florida Statute 627.736 nor the policy of insurance that would impose a requirement that the insured must pay the deductible before an insurer’s obligation would ripen. Defendant’s argument is contrary to the purpose of the Florida No Fault Law “[I]nsurance coverage that is a creature of statute is not susceptible to the attempts of the insurer to limit or negate the protection afforded by law” Salas v. Liberty Mutual Fire Insurance Company, 272 So.2d 1 (Fla. 1972). “[R]estrictions on statutorily mandated coverage must be carefully examined because exclusions that are inconsistent with the purpose of the statute are invalid. Vasques v. Mercury Casualty Company, 947 So.2d 1265 (Fla. 5th DCA 2007) [32 Fla. L. Weekly D363a]. (emphasis added).
Based upon the aforementioned, this Court finds that there is competent substantial record evidence to support Plaintiff’s claims that the bills from Sheridan Children’s Health and Plantation General Hospital were properly applied to the Claimant’s deductible. Once properly applied to the deductible, and never having been denied, notwithstanding the passing of the statute of limitations, said bills cannot thereafter be “un-applied” from said deductible.
Accordingly, this Court finds that there are no genuine issues of material fact and after applying the remainder of the claimant’s deductible to the Plaintiff’s bills at issue for dates of service July 10, 2003 through August 12, 2003 totaling $2,185.00, the amount exceeding the deductible and payable by the Defendant, UNITED AUTOMOBILE INSURANCE COMPANY, is $795.20. Therefore the Plaintiff is entitled to judgment in the amount of $795.20 plus interest from the date the claim first became overdue.
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1Prior to the July 2003 revision, the deductible was applied to the 80% of the amount billed. i.e. The total billed $1,309.00 x .80 = $1,047.20 which is then applied to the $2,000.00 leaving balance of $952.80.
2At the hearing, UNITED presented no admissible evidence that the insured failed to pay his deductible, however, the Court concludes that whether the claimant actually paid his deductible or not is irrelevant.
3UNITED also conceded at the hearing that the first bills received (Sheridan Children’s Health and Plantation General Hospital) were reasonable, related and necessary.
