14 Fla. L. Weekly Supp. 1062c
Insurance — Personal injury protection — Coverage — Medical expenses — Reasonable charges — Insurer’s policy of uniformly paying certain procedure codes at 200% of workers’ compensation statute or Medicare Part B fee schedule does not violate PIP statute — If medical provider disagrees with payment, it may sue and bears burden of proving charges are reasonable
INTEGRA HEALTH SERVICES, INC., (Malik Asalieh), Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-3826 COCE 56. August 22, 2007. Linda R. Pratt, Judge.
ORDER ON MOTION FOR SUMMARY JUDGMENT
This cause is before the Court on plaintiff’s motion for summary judgment on count II of its complaint, and defendant’s motion for summary judgment on both counts I & II. Upon consideration of the record, the Court finds as follows:
In Count I plaintiff claims defendant breached its contract of insurance by failing to pay 80% of reasonable and customary charges for various services it rendered to defendant’s insured. In some instances, defendant paid less than 80% of what plaintiff billed, with the explanation that reimbursement was limited to the maximum allowable amount of 200% of the Medicare Part B Participating Physician Fee Schedule, or The Florida Workers’ Compensation Statute.
In Count II, plaintiff seeks a declaratory judgment that defendant’s policy of uniformly paying certain procedure codes at 200% of either Medicare Part B or the Florida Workers’ Compensation Statute violates F.S. 627.736.
Plaintiff argues that the history of PIP legislation makes clear that the legislature specifically declined to adopt a fee schedule for all but a handful of medical services and procedures, and that defendant is therefore circumventing the legislative intent by use of the Medicare and Workers’ Compensation fee schedules to set its rate of reimbursement. The Court agrees that “Legislative intent is the polestar that guides a court’s inquiry under the No Fault Law”, United Automobile Insurance Company v. Rodriguez, 808 So. 2d 82, 85 (Fla. 2000).
For purposes of this case, the legislative intent is clearly expressed in F.S. 627.736(5)(a), which was added to the law in 2003:
With respect to a determination 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.
The court finds that the above statute allows insurers to choose for themselves which of the several stated factors to consider in determining what is reasonable. Defendant has chosen to use a federal and a state fee schedule applicable to other insurance, to wit the Medicare and Workers’ Compensation schedule. Defendants’ decision to use these fee schedules is not dispositive, however. If plaintiff disagrees with payment, it may sue, but it bears the burden of proving its charges were reasonable. State Farm Mutual Automobile Association v. Sestile, 821 So. 2d 1244 (Fla. 2 DCA 2002).
Based upon the foregoing, plaintiff’s motion for summary judgment on Count II is denied, and defendant’s motion as to Count II is granted. Defendant’s motion for summary judgment as to Count I is denied, because there remains an issue of material fact in dispute as to whether or not defendant paid 80% of all reasonable charges submitted by plaintiff.
