20 Fla. L. Weekly Supp. 149c
Online Reference: FLWSUPP 2002JONEInsurance — Personal injury protection — Coverage — Where policy does not reference permissive fee schedule of section 627.736(5)(a)2, PIP insurer is required to reimburse 80% of reasonable medical expenses pursuant to mandatory language of PIP statute
EDGE FAMILY CHIROPRACTIC, P.A. dba Edge Family Chiropractic a/a/o Barbara Jones, Plaintiff, vs. ALLSTATE INSURANCE COMPANY, Defendant. County Court, 1st Judicial Circuit in and for Escambia County. Case No. 2011 SC 004086, Division 5. October 11, 2012. Pat Kinsey, Judge. Counsel: Robert N. Heath, Jr., Robert N. Heath, P.A., Pensacola, for Plaintiff. Michelle L. Hendrix, for Defendant.
ORDER GRANTING PLAINTIFF’SMOTION FOR SUMMARY DISPOSITION
At a hearing in open court on October 4, 2012, the court heard both the plaintiff’s and defendant’s motions for summary disposition. The parties appeared through counsel to argue their positions supported by their excellent motions and memoranda of law. The parties stipulated to all material facts leaving only their arguments on the law to be considered by the court in this PIP case.
Plaintiff submitted certain bills for medical services rendered to defendant insurance company for payment. It is undisputed that defendant paid a reduced amount on the invoices submitted. The sole issue before the court is whether or not defendant was required to pay 80% of all reasonable charges for the services rendered or if defendant was authorized under their policy to limit payments pursuant to the fee schedule in §627.736(5)(a)(2), Florida Statutes.
The court agrees with the plaintiff that the limitations permitted by §627.736(5)(a)(2), Florida Statutes are not adequately incorporated into the policy issued to the assignor, Edward Hackett. Defendant’s policy states that when an insured is injured in a covered motor vehicle collision they will pay “eighty percent of reasonable expenses for medically necessary medical, surgical, x-ray, dental and rehabilitative services. . .” and “. . . any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736 or any other provisions of the Florida Motor Vehicle No-Fault Law, as enacted, amended or otherwise continued in the law, including but not limited to, all fee schedules.” It is undisputed that there is no specific reference to §627.736(5)(a)(2), Florida Statutes.
In Kingsway Amigo Insurance Co., v. Ocean Health, 63 So.3d 63 (Fla. 4th DCA 2011) [36 Fla. L. Weekly D1062a], the court found that an insurance company wishing to take advantage of the permissive §627.736(5)(a)(2), Florida Statutes language rather than the mandatory 80% language in the PIP statutes must “clearly and unambiguously select that payment methodology in a manner so that the insured patient and health care providers would be aware of it.” Id. at 68.
“Ambiguities in insurance contracts are resolved in favor of the insured.” Geico Indemnity Co. v. Virtual Imaging Services, Inc., 79 So.3d 55, 58 (Fla. 3rd DCA 2012) [36 Fla. L. Weekly D2597a]. A policy which allowed an insurance company to reimburse according to one method without clarifying alternative methods or identifying the factors to be considered is ambiguous. Id. The Fourth DCA followed the same reasoning in DCI MRI, Inc., v. Geico Indemnity Co., 79 So.3d 840 (Fla. 4th DCA 2012) [37 Fla. L. Weekly D170e].
Here the court finds that Allstate may have intended to incorporate the §627,736(5)(a)(2), Florida Statutes, permissive language accessing fee schedules as an alternative to paying 80% of reasonable and related medical expenses, but their poorly drafted policy failed to meet the “clear and unambiguous” requirements of Kingsway and Geico v. Virtual Imaging. Allstate’s policy never makes reference to §627.736(5)(a)(2), Florida Statutes and/or never makes any statement that defines what “other provisions” means or what “other limitations” could be imposed.
Therefore, without specific reference to §627.736(5)(a)(2), Florida Statutes, Allstate is required to reimburse pursuant to the mandatory language of the PIP statute at 80% of reasonable medical expenses.
ORDERED AND ADJUDGED that plaintiff’s motion for summary disposition is granted and defendant’s motion for summary judgment (disposition) is denied.
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