10 Fla. L. Weekly Supp. 113a
Insurance — Personal injury protection — Coordination of benefits between PIP insurer and health insurer, with insured contending PIP benefits should have been used to pay his lost earnings and health insurer should pay hospital bill — Level of coordination required of PIP insurer by statute is unclear — Where PIP adjuster spoke with insured and insured’s attorney and made one phone call to health insurer, attempt to coordinate benefits was legally sufficient — In absence of clear choice for resolution of competing claims for hospital bill and lost wages, PIP insurer’s issuance of joint draft payable to insured and hospital was legally valid option
RICARDO HERNANDEZ, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. CCO-01-10. Division 71. December 30, 2002. C. Jeffery Arnold, Judge. Counsel: Dawn Ikerd, Ikerd & Matthews, P.A., Orlando, for Plaintiff. Mimi Smith, David A. Sierra & Associates, Orlando, for Defendant.
ORDER GRANTING DEFENDANT, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY’S, MOTION FOR SUMMARY JUDGMENT REGARDING LOST-WAGES CLAIM
This cause came before this Court on the 9th day of December, 2002, upon the Defendant’s, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY’s, Motion for Summary Judgment Regarding Lost-Wages Claim. The Court, having reviewed the Defendant’s motion, court file, affidavits, and the Plaintiff’s Memorandum of Law in Opposition to the Defendant’s Motion for Summary Judgment, makes the following findings of fact and conclusions of law:
The undisputed facts relevant to the issues in this motion are as follows:
The Plaintiff filed a lawsuit for PIP benefits pursuant to Fla. Stat. 627.736. The claim for PIP benefits arose out of a motor vehicle accident that occurred on February 4, 1997. The Plaintiff incurred expenses for medical treatment, including the bills of healthcare providers. The Plaintiff also alleged that he was entitled to lost wages as a result of injuries he incurred in this accident.
From March 3, 1997 to June 24, 1999, State Farm received and paid the bills of the Plaintiff and his medical providers to the point of exhausting the $10,000 in PIP benefits and the $5,000 in medical payments benefits that were available from the Plaintiff’s policy. After June 16, 1999, there was approximately $701.42 left in PIP coverage and approximately $2,676.23 left in medical payments coverage.
On June 10, 1999, the Plaintiff had a conversation with the State Farm claims adjuster and discussed the fact that he had shoulder surgery on June 3rd and June 4th, 1999 at Health Central Hospital, and that he had been out of work, due to the surgery, and was seeking lost wages. On June 16, 1999, State Farm received the wage-loss form from the Plaintiff’s employer. Three days later, on June 19, 1999, State Farm received the Health Central bill, along with a lien, for the shoulder surgery in the amount of $8,099.25.
The State Farm claims adjuster had several communications with the Plaintiff’s attorney and made one phone call to the Plaintiff’s health insurance company, Benefit Planners, to attempt to coordinate benefits so that Benefit Planners would pay the hospital bill and State Farm would pay the remaining $701.42 toward the lost-wages claim. When it became obvious that Benefit Planners was refusing to cover the Health Central surgery bill, State Farm issued a draft for the Plaintiff’s remaining benefits jointly to the Plaintiff and Health Central.
State Farm argued that, even if State Farm received the Plaintiff’s wage-loss form a few days before it received the Health Central bill, these represented competing claims since the Health Central bills came in well before the wage-loss claim was overdue. Fla. Stat. 627.736. Furthermore, the claims adjuster became aware of the hospital bill at the same time that he became aware of the lost-wages claim, during the conversation with the Plaintiff on June 10th. Therefore, State Farm argued, the insurer was obligated by law to use the PIP funds first for the hospital bill. Allstate Indemnity Co. v. Miriam Leon and PacifiCare of Florida, Incorporated, 6 Fla. Law Weekly Supp. 675a, (Circuit Court, 11th Judicial Circuit in and for Miami-Dade County, Appellate Division, Case No. 99-003AP. No. 97-7879CC (05). A hospital lien takes priority over lost wages and other PIP benefits. Mirta Fernandez, as Personal Representative of Angel Fernandez, Deceased, v. South Carolina Insurance Co., 408 So. 2d 753 (3rd DCA 1982).
State Farm cited several cases which stood for the rule that, if an insurer is faced with competing claims and is uncertain as to which claim to pay, it must issue a joint draft or interplead the funds at issue. Marcus Margiotta v. State Farm Mutual Automobile Insurance Company, 622 So. 2d 135 (4th DCA 1993), Anthony Logue v. Clarendon National Insurance Company and Herbert Koltun, 777 So. 2d 1122 (4th DCA 2001).
The Plaintiff argued that State Farm failed to apportion the Plaintiff’s claim so as to secure the maximum available benefits, pursuant to Holloway v. State Farm, 370 So. 2d 452 (Fla. 4th DCA 1979) and Howell-Demarest v. State Farm, 673 So. 2d 526 (Florida 4th DCA 1996). Specifically, the Plaintiff argued that the lost-wages claim was made prior to State Farm receiving notification of the hospital bill and lien.
The Plaintiff asserted that State Farm never made an effort to determine whether the hospital lien was valid, nor did it determine that the hospital had a PPO arrangement with the health insurer, Benefit Planners. Furthermore, the Plaintiff argued, State Farm failed to follow its statutory duty to coordinate benefits pursuant to Fla. Stat. 627.4235(1) and Fla. Stat. 627.7401.
Defendant, State Farm, argued that neither the language of Fla. Stat. 627.4235 nor the language of Fla. Stat. 627.7401 requires PIP carriers to coordinate PIP benefits with HMO coverage. Allstate v. Leon & PacifiCare, 6 Fla. Law Weekly 675a [6 Fla. L. Weekly Supp. 675a]. Defendant argued that Fla. Stat. 627.7401 only imposes an obligation on the Department of Insurance to furnish forms with which to coordinate potential benefits. Fla. Stat. 627.4235 states that group health carriers, not PIP carriers, have a duty to coordinate and maximize benefits. Yoshida v. State Farm, 8 Fla. Law Weekly Supp. (b) [8 Fla. L. Weekly Supp. 321b].
This Court finds that, although the statutes at issue may require a PIP insurer to coordinate a claimant’s benefits with that of the claimant’s health insurer, the level of coordination required is unclear. In this case, the State Farm adjuster spoke with the Plaintiff, the Plaintiff’s attorney, and made one phone call to the health insurance carrier. The Court finds that this attempt to coordinate benefits was legally sufficient under this set of facts.
The Court finds that State Farm was faced with the competing claims of the hospital bill and lien and the lost-wages claim. The adjuster had several legitimate options. In the absence of a clear choice, the issuance of a joint draft payable to the Plaintiff and the hospital was a legally valid option.
WHEREFORE, the Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY’s, Motion for Summary Judgment regarding the lost-wages claim, is hereby granted.
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