18 Fla. L. Weekly Supp. 1203b
Online Reference: FLWSUPP 1811BARI
Insurance — Personal injury protection — Coverage — MRI — 2008 PIP statute which limits amount insurers reimburse medical providers for MRI services does not apply retroactively to policy in effect before effective date of statute — PIP statute does not authorize insurer to cap reimbursement pursuant to Outpatient Prospective Payment System
THE IMAGING CENTER OF WEST PALM BEACH, LLC, (Patient: Carlos Barillas), Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County, Civil Division. Case No. 502008SC008060XXXXMB, Division ‘RB.’ September 23, 2011. Caroline Cahill Shepherd, Judge. Counsel: Nicholas A. Zacharewski, Ellis, Ged & Bodden, P.A., Boca Raton, for Plaintiff. Mark J. Rose, for Defendant.
FINAL SUMMARY JUDGMENT
THIS MATTER came before the Court on March 21, 2011 on Plaintiff’s and Defendant’s competing Motions for Summary Judgment as to the issue of Defendant, State Farm Mutual Automobile Insurance Company’s failure to fully pay personal injury protection benefits for magnetic resonance imaging (MRI) services provided to Carlos Barillas. The Court heard arguments of counsel and after otherwise being fully advised of the premises of the parties’ respective motions, as well as supplemental authority, the Court finds as follows:
As stated in Plaintiff’s Motion for Final Summary Judgment, the following facts are not in dispute:
1. Carlos Barillas (hereinafter the “Claimant”) was involved in an automobile accident on January 11, 2008, in which he sustained injuries which required medical treatment. The Imaging Center of West Palm Beach, LLC (hereinafter “Plaintiff”) later submitted bills for medical treatment to State Farm Mutual Automobile Insurance Company (hereinafter “Defendant”) related to the January 11, 2008 accident.
2. The claimant, Carlos Barillas entered into a contract for insurance with Defendant which provided personal injury protection benefits and medical payments coverage. The policy was in full force and effect on January 11, 2008, and provided PIP and medical payments coverage for the injuries that Carlos Barillas suffered in the motor vehicle accident. The subject policy provides:
“We will pay, in accordance with the Florida Motor Vehicle No-Fault Law, to or for the benefit of covered person: 1) medical benefits, and 2) work loss; and 3) Replacement services expenses; and 4) death benefits equal to the lesser of a. $5,000.00; or b. the remainder of unused personal injury protection benefits.”
3. State Farm has paid $6,602.88 in benefits to date.
4. On January 30, 2008 and February 21, 2008, Plaintiff received services at The Imaging Center of West Palm Beach, LLC which included CPT codes 73221 and 72141, which are MRI’s of the upper extremity and the cervical spine.
5. The Imaging Center of West Palm Beach, LLC submitted its bill for services which was received by State Farm on March 27, 2008. The total amount submitted for CPT Codes 73221 and 72141 was $3,600.00.
6. On March 31, 2008, State Farm made payment to The Imaging Center of West Palm Beach, LLC, in the amount of $1,380.48 for CPT Codes 73221 and 72141.
7. Plaintiff submitted a notice of intent to initiate ligation for personal injury protection. The demand was denied by Defendant and Plaintiff filed the instant action for breach of contract alleging the failure to pay the proper amount personal injury protection benefits for the services provided.Standard of Review
Summary Judgment is appropriate where the pleadings, depositions, answer to interrogatories and admissions, together with any affidavits, show that there is no genuine issue of material fact. Fla. R. Civ. P. 1.510(c). Summary Judgment “shall be rendered forthwith [when the evidence shows] there is no genuine issue as to material fact and that the moving party is entitled to a judgment as a matter of law.” Fla. R. Civ. P. 1.510.
The purpose of a motion for summary judgment is to determine if there is sufficient evidence to justify a trial upon the issues made by the pleadings. Odham v. Foremost Dairies, 128 So.2d 586 (Fla. 1966). When the moving party establishes that there is no genuine issue of material fact, that party is entitled to summary judgment, Holl v. Talcott, 191 So.2d 40 (Fla. 1961). Stated otherwise, the purpose of summary judgment is to obviate expense and delay of summoning a jury to try facts that are not in conflict. Anderson v. Maddox, 65 So.2d 299, 300 (Fla. 1953). When a dispute over facts has been eliminated, the trier of fact need not be called, and the trier of law then determines the proper decision to be rendered. Id.
To avoid summary judgment, a Plaintiff must demonstrate specific material facts in dispute and must come forward with sufficient evidence for each element of the case. It is not enough for the Plaintiff merely to assert that an issue exists. Publix Supermarkets, Inc. v. Austin, 658 So.2d 1064 (Fla. 5th DCA 1995) [20 Fla. L. Weekly D1531b]. Instead, the Plaintiff “must demonstrate the existence of such an issue either by countervailing facts or justifiable inferences from the facts presented. If he fails in this, he must suffer a summary judgment against him.” Harvey Bldg. v. Haley, 175 So.2d 780, 783 (Fla. 1965).
It is
ORDERED AND ADJUDGED that Plaintiff’s Motion for Summary Judgment is GRANTED. The policy at issue was effective December 18, 2007, predating the effective date of Fla. Stat. §627.736(5)(a)(2), (3) and (4), which was January 1, 2008. The effect of applying the 2008 statute to the parties’ relationship here would be to substantively affect their rights under the contract. See Progressive Express Ins. Co., Inc. v. Menendez, 979 So.2d 324, 330 (Fla. 3d DCA 2008) [32 Fla. L. Weekly D2891a]. Therefore the Court will not impose sections of the statute to restrict or limit the amounts Plaintiff is due for MRI services provided to the Claimant. Further, the PIP statute does not authorize an insurance company to cap reimbursement pursuant to the Outpatient Prospective Payment System (OPPS). See also, Nationwide Mutual Fire Ins. Co. v. AFO Imaging, Inc., 2011 WL 2622311 (Fla. App. 2 Dist.).
Fla. Stat. §627.736 (2007) was not in effect when the policy was entered into between Defendant and its insured (policy period December 18, 2007 through June 18, 2008) and Fla. Stat. §627.736 (2008) did not become effective until January 1, 2008. It is generally accepted that the law in effect at the time the contract is executed governs the parties’ rights and substantive issues arising under the contract. Hausler v. State Farm Mutual Automobile Ins. Co., 374 So.2d 1037 (Fla. 3d DCA 1979) and Hassen v. State Farm Mutual Automobile Ins. Co., 674 So.2d 106 (Fla. 1996) [21 Fla. L. Weekly S102c].
The policy does not authorize an insurance company to cap reimbursement pursuant to the Outpatient Prospective Payment System (OPPS). Therefore, Defendant must either limit payment to 80% of 200% of the participating physicians fee schedule of Medicare Part B or pay 80% of the reasonable amount billed.
It is
ORDERED AND ADJUDGED that Defendant’s Motion for Summary Judgment is DENIED. Defendant, State Farm Mutual Automobile Insurance Company, shall take nothing by this action and that the Plaintiff, The Imaging Center of West Palm Beach, LLC, shall go hence without day.
It is further
ORDERED AND ADJUDGED that this Court retains jurisdiction to determine entitlement to attorney’s fees and costs and the reasonable amount thereof.
