13 Fla. L. Weekly Supp. 87a
Insurance — Personal injury protection — Coverage — Medical expenses — Reduction — Where insured provided evidence that therapeutic pillow was reasonable, related and medically necessary and that amount charged for pillow was reasonable, insurer’s decision to reduce charge to 20% over invoiced cost of pillow failed to meet requirements of no-fault statute
ASHLEY LEE HOLLOWAY, III, Plaintiff, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 4th Judicial Circuit in and for Duval County, Small Claims. Case No. 16-2003-SC-11901, Div. K. October 6, 2005. Sharon H. Tanner, Judge. Counsel: Ellen C. Pappas Thompson. David G. Candelaria, Farah & Farah, P.A., Jacksonville.ORDER
THIS CAUSE coming before the Court sub judice on “Plaintiff’s Motion For Partial Final Summary Disposition,” and after considering argument of counsel and relevant Florida Law, the Count finds:
1. Plaintiff was injured while walking as a pedestrian on December 17, 2002. Plaintiff sought payment for his medical services from a policy of insurance between Kevin Sessions (hereafter “insured”), and Defendant Progressive Express Insurance Company (hereafter “Defendant”).
2. As a result of the accident Plaintiff has suffered injuries to his neck and knee that necessitated medical treatment from Physical Medicine Associates, Dr. Robert W. Sury, M.D.
3. Defendant, through its automobile insurance policy with insured, expressly agreed in their insurance policy that the Defendant would pay 80% of all medical expenses to a limit of $10,000.
4. On April 28, 2003, Dr. Sury prescribed a Tempur-Pedic pillow for the Plaintiff. Plaintiff received the Tempur-Pedic pillow from Physical Medicine Associates who thereafter submitted charges to Defendant for payment of No-Fault benefits for said pillow (CPT 99070) in the amount of $79.00.
5. After receiving Plaintiff’s charges, Defendant reduced the amount charged to $56.58 and stated in their explanation of benefit that “[s]upplies are reimbursed at cost & 20% Mark Up.”
6. Fla. Stat. § 627.736(5)(a) states in relevant part that:
“Any physician . . . rendering treatment to an injured person for a bodily injury covered by personal injury protection insurance may charge the insurer . . . only a reasonable amount . . . for the supplies rendered . . . . With respect to a determination of whether a charge for a particular service . . . 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.”
7. Plaintiff provided evidence that the Tempur-Pedic pillow was reasonable, related and medically necessary. Additionally, Plaintiff provided evidence that the amount charged by Physical Medicine Associates was reasonable in amount, and there was no evidence in the record stating otherwise.
8. Defendant’s decision to reduce Plaintiff’s charges based on a percentage over the invoice prices fails to meet the requirements Florida’s No-Fault Statute.
9. Defendant owes the Plaintiff $17.94 (80% of $22.42, the amount reduced by Defendant), plus statutory interest as required by Fla. Stat. § 627.736(4)(c)(2003).
It is upon due consideration
ORDERED
1. Plaintiff’s Motion For Final Partial Summary Disposition is GRANTED.
2. This Court finds that the Plaintiff is entitled to attorneys fees and costs pursuant to §§ 627.736 and 627.428, Florida Statutes, as the prevailing party, and reserves jurisdiction to enter a Final Judgment on attorney’s fees and costs accordingly.
3. This Court reserves jurisdiction to enforce this Final Judgment, as well as any previous Judgements and/or Orders in this matter, and to do any and all other acts necessary in this cause.
