18 Fla. L. Weekly Supp. 226a
Online Reference: FLWSUPP 1802BARR Insurance — Personal injury protection — Coverage — Where provision of 2008 PIP statute allowing insurer to limit reimbursement to 200% of Medicare fee schedule is permissive, clear and unambiguous policy language providing that insured will pay 80% of reasonable expenses controls reimbursement
QUALITY MEDICAL GROUP, INC., a/a/o GROVER BARRIENTOS, Plaintiff, vs. MERCURY INSURANCE COMPANY OF FLORIDA, Defendant, County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 08-25313 SP 23 (03). November 3, 2010. Linda Singer Stein, Judge.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AND DENYING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT
THIS cause came before the Court on Cross-Motions for Summary Judgment.
The sole issue in the Motions is how Defendant should calculate the amount to pay to Plaintiff.
Findings of Fact
The Plaintiff sued the Defendant on or about July 1, 2008 alleging violation of Section 627.736 and breach of contract, seeking to enforce the payment of PIP benefits arising out of a motor vehicle accident that occurred on or about 1/1/2008. The plaintiff sued the Defendant for medical expenses in the amount of $4,511.86 for services rendered to Grover Barrientos for dates of service 1/4/08 through 2/15/08.
On or about 11/19/09, the Defendant filed its’ Answer and Affirmative Defenses alleging that it issued payment in pursuant to 200% of the Medicare Part B fee schedule allowed under the 2008 PIP statute. The subject policy insurance was effective from 10/22/07 through 4/22/08.
The Florida Legislature allowed the Florida Motor Vehicle No-Fault Law to automatically repeal on 10/1/07 pursuant to a “sunset” provision. Thereafter, effective 1/1/08, the Legislature enacted a new set of statutes as the Florida Motor Vehicle No-Fault Law, which included a newly revised version of Section 627.736. Effective January 1, 2008, Fla. Stat. Section 627.736(5)(a)(2)(2008) was amended to allow a PIP insurer to issue payment at 200% of the Medicare Part B Fee Schedule. However, like the prior PIP statute, the revised version requires that PIP insurers “shall” provide reimbursement of 80% of an insured’s “reasonable” medical expenses. The Defendant issued payment at 200% of Medicare Part B pursuant to a permissive fee schedule contained in Fla. Stat. Section 627.736(5)(a)(2)(2008) for medical services rendered to Grover Barrientos.
The policy at issue states, “We will pay to or on the behalf of the injured person the following benefits . . . in accordance with the Florida Motor Vehicle No-Fault Law, as amended, for; 1. Medical Expenses; EIGHTY PERCENT (80%) OF ALL REASONABLE EXPENSES FOR MEDICALLY NECESSARY medical surgery, X-ray, dental, and rehabilitative services, including prosthetic devices, and medically necessary ambulance, hospital, and nursing services.
Conclusions of Law
The language of the policy is clear and unambiguous. When the terms of the insurance contract are clear and unambiguous, the expenses terms control. Armstrong v. State, 985 So.2d 1156 (Fla.3rd DCA 2008) [33 Fla. L. Weekly D1594a]; See also Premier Neurological Treatment Centers, Inc. a/a/o John McCray v. ASAA Casualty Insurance Co., Case No. 08-13411 COCE 50 (Fla.17th Cir. 2009) [16 Fla. L. Weekly Supp. 1188a]. As such, the Defendant is responsible for payment of eighty percent of the all reasonable, related, and necessary medical expenses which are not limited by the 2008 fee schedule.
Accordingly, Final Summary Judgment is entered in favor of Plaintiff, QUALITY MEDICAL GROUP, INC. a/a/o Grover Barrientos and Defendant’s Motion for Summary Judgment is DENIED.
