18 Fla. L. Weekly Supp. 610b
Online Reference: FLWSUPP 1807BALL
Insurance — Personal injury protection — Discovery — Because medical provider is required to prove reasonableness of charges before determination can be made regarding claim that insurer improperly applied deductible to charges, insurer is entitled to engage in discovery relating to reasonableness of charges — Copies of agreements between provider and HMOs, PPOs, and other private insurance in effect on date of service at issue for the CPT codes at issue are discoverable — Plaintiff to produce for deposition its corporate representative with the most knowledge of plaintiff’s claim and reimbursement rates accepted by plaintiff for same or similar charges and to produce documentation requested by defendant
FLAGLER HOSPITAL, INC., As Assignee of Mitchell R. Ball, Plaintiff, vs. MGA INSURANCE COMPANY, Defendant. County Court, 7th Judicial Circuit in and for St. Johns County. Case No. SP10-2030, Div. TIN. March 18, 2011. Honorable Charles J. Tinlin, Judge. Counsel: Bobbie Celler, for Plaintiff. James S. Gentry, Dutton Law Group, P.A., Longwood, for Defendant.
ORDER ON DEFENDANT’S MOTION TO COMPEL DEPOSITIONS AND PLAINTIFF’S MOTION FORPROTECTIVE ORDER AND PLAINTIFF’S MOTIONFOR EXTENSION OF TIME TO RESPOND TO DEFENDANT’S PROPOSAL FOR SETTLEMENT
THIS MATTER came on to be heard before the Honorable Charles J. Tinlin on March 9, 2011, on the Defendant’s Motion to Compels Depositions and Plaintiff’s Motion for Protective Order and Plaintiff’s Motion for Extension of Time to Respond to Defendant’s Proposal for Settlement and the Court after having considered the Motions, reviewed the pleadings, considered argument of counsel, and otherwise fully advised in the premises, it is hereby:
ORDERED AND ADJUDGED that:
1. The parties agree that the Plaintiff’s Motion for Extension of Time to Respond to Defendant’s Proposal for Settlement is GRANTED to the extent that the Plaintiff has Sixty (60) days to respond to the Defendant’s Proposal for Settlement.
2. The Defendant’s Motion to Compel Depositions and Plaintiff’s Motion for Protective Order involve the same subject matter and are dealt with accordingly.
3. The Plaintiff has filed this action seeking reimbursement for Personal Injury Protection (PIP) benefits under a policy of insurance issued by the Defendant.
4. The Plaintiff contends this action concerns only an issue of law; more specifically, the Plaintiff claims that the Defendant improperly applied the insured’s deductible to the Plaintiff’s charges and that, therefore, any depositions of the Plaintiff are unnecessary and burdensome.
5. The Defendant contends that the key factor to be determined in any action for PIP benefits is the reasonableness of the Plaintiff’s charges and that any consideration of the Plaintiff’s Motion for Summary Judgment prior to the deposition Plaintiff’s corporate representative would be premature. In support of this contention the Defendant relies, in part, on Allstate Insurance Company v. Holy Cross Hospital 961 So. 2d 328, 335 (Fla. 2007) [32 Fla. L. Weekly S453a], and the wording of F.S. §627.736(5)(a)(1).
A review of F.S. §627.736(5)(a)(1) makes it abundantly clear that an insurer is only required to pay a “reasonable” amount for medical bills submitted under a claim for PIP coverage. Specifically the statute states: (a)1. Any physician, hospital, clinic, or other person or institution rendering treatment to an injured person for a bodily injury covered by personal injury protection insurance may charge the insurer and injured party only a reasonable amount pursuant to this section for the services and supplies rendered, and the insurer providing such coverage may pay for such charges directly to such person or institution lawfully rendering such treatment, if the insured receiving such treatment or his or her guardian has countersigned the properly completed invoice, bill, or claim form approved by the office upon which such charges are to be paid for as having actually been rendered, to the best knowledge of the insured or his or her guardian. In no event, however, may such a charge be in excess of the amount the person or institution customarily charges for like services or supplies. With respect to a deter-mination of whether a charge for a particular service, treatment, or otherwise is reasonable, consideration may be given to evidence of usual and customary charges and payments accepted by the provider involved in the dispute, and reimbursement levels in the community and various federal and state medical fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service, treatment, or supply. (emphasis added)
6. As a matter preliminary to the determination of the “allowable amount” and applicable “payment limitation” under section 627.736(5)(a)2f, Florida Statutes (2007-2008) the provider must first plead and prove that its charges are “reasonable.” State Farm Mutual Automobile Ins. Co., v. Sestile, 821 So. 2d 1244, 1246 (Fla. 2d DCA 2002) [27 Fla. L. Weekly D1757a]; Auto Owners Ins. Co. v. Marzulli, 788 So. 2d 1031, 1034 (Fla. 2d DCA 2001) [26 Fla. L. Weekly D734a]; Derius v. Allstate Indemnity Co., 723 So. 2d 271, 272 (Fla. 4th DCA 1998) [23 Fla. L. Weekly D1383a].
7. Thus, before any determination can be made regarding the application of the policy deductible to the Plaintiff’s bills the Plaintiff must first prove it’s bills are reasonable and the Defendant is entitled to engage in discovery as to the reasonableness of the Plaintiff’s charges.
8. The Defendant seeks the production of copies of all HMO and PPO agreements between provider (or any entity to which the provider provided medical services) and any other private insurance in effect on the date of service at issue for the CPT codes at issue.
9. The documents sought by the Defendant are discoverable as what a provider customarily has previously accepted for its medical services are important factors for determining whether a fee is reasonable. Allstate Insurance Company v. Holy Cross Hospital 961 So. 2d 328, 335 (Fla. 2007) [32 Fla. L. Weekly S453a]; Kerry Haskins, M.D. a/a/o Teres Kemp v. Progressive Consumers Ins. Co., 12 Fla. L. Weekly Supp. 880a (Fla. Hillsborough Cty. Ct. 2005)
10. The Plaintiff shall produce for deposition its corporate representative with the most knowledge of the Plaintiff’s claim and reimbursement rates accepted by the Plaintiff for the same or similar charges from HMO, PPOs, private insurance programs, Medicare, workers compensation within Forty-five (45) days.
11. The Plaintiff shall bring all the documents listed above and any other documentation requested by the Defendant unless otherwise Ordered by this Court.
