20 Fla. L. Weekly Supp. 389a
Online Reference: FLWSUPP 2004NBURInsurance — Personal injury protection — Coverage — Medical expenses — Deductible — Claims need not be applied to deductible within 30 days so long as there is a “reasonable basis” for denying the claim — Where insurer initially denied claims based on a coverage investigation regarding alleged material misrepresentations made by insured in her insurance application, and trial court determined that these defenses were not meritorious, insurer thereafter properly applied the bills and determined that the costs were within the deductible — Trial court erred in awarding payment to provider
UNITED AUTOMOBILE INSURANCE COMPANY, a Florida corporation, Appellant, v. RIVERSIDE MEDICAL ASSOCIATES, INC. a/a/o NORMANDEL BURKE, Appellee. Circuit Court, 17th Judicial Circuit (Appellate) in and for Broward County, Florida. Case No. 11-004047 CACE (05). Consolidated with 11-020850. L.T. Case No. 04-010641 COCE (54). Lisa Trachman, Judge. December 13, 2012. Counsel: Thomas L. Hunker, Miami, for Appellant. Henry A. Seiden, West Palm Beach, for Appellee.OPINION
(RICHARD D. EADE, J.) THIS CAUSE came before the court, sitting in its appellate capacity, upon an appeal by United Automobile Insurance Company (“UAIC”) of the trial court’s final judgment in favor of Riverside Medical Associates Inc. (“Riverside”). The court, having considered the briefs filed by the parties, having heard argument of counsel, and being duly advised in premises and law, finds and decides as follows:
Riverside is a chiropractic therapy facility and assignee of Personal Injury Protection (“PIP”) benefits of Normandel Burke (“Burke”). Burke was insured by UAIC, and her policy contained a $2,000 deductible. Following an automobile accident on September 23, 2003, Riverside rendered medical services to Burke over the course of eight chiropractic visits, between September 26, 2003 and March 15, 2004, for a total amount of $1,574. However, the trial court, constrained by the pleadings, considered seven medical visits, which amounted to $1,399. At the trial court hearing on February 2, 2011, Riverside waived its bill for services rendered in March 2004 to prevent preclusion of summary judgment on any factual issues.
Burke also received medical treatment from Stand Up MRI (“Stand Up”) in the amount of $1,219.However, on August 12, 2004, Stand Up settled its bill with Burke for $600 and discharged the remaining $619. The total bill for medical services rendered by both providers and considered by the trial court was $2,618. UAIC never made any payments for medical services to either provider (Riverside or Stand Up). On August 10, 2004, UAIC notified Riverside that it would be unable to provide benefits for Burke based on material misrepresentations that rendered the policy void from its inception.
On February 2, 2011, the trial court granted Riverside’s motion for final summary judgment, awarding Riverside $94.42. This amount represented 80% of $2,618, the total for all medical services rendered, less the $2,000 policy deductible. The trial court reserved jurisdiction to consider attorney’s fees and costs upon motion and notice. On August 18, 2011, the trial court ruled that Riverside is entitled to $58,972.50 in attorney’s fees, $5,248.30 in taxable costs, and $2,074.82 in prejudgment interest, for a total recovery of $66,295.62.
On February 15, 2011, UAIC timely filed its Notice of Appeal of the trial court’s final judgment. On August 30, 2011, UAIC filed its Notice of Appeal of the trial court’s order granting plaintiff’s motion awarding attorney’s fees and costs. This Court consolidated the two appeals and held oral argument on July 9, 2012.
Riverside cross appealed the trial court’s order denying its amended motion for sanctions and exemption from mediation privilege and confidentiality. A cross appeal is the appellee’s
exclusive method of requesting relief from the order appealed by the appellant. See Breakstone v. Baron’s of Surfside, Inc., 528 So. 2d 437 (Fla. 3d DCA 1988) (holding that the function of a cross appeal is to call into question error in the judgment appealed). This court considered Riverside’s cross appeal “as the equivalent of a separate appeal.” See Ord. Jun 15, 2012.1 However, without cross-appealing the final judgment on fees, this Court cannot address the merits of Riverside’s appeal.2
When an order under review rests purely on legal matters, that order is subject to full, or de novo, review on appeal. See Operation Rescue v. Women’s Health Center, Inc., 626 So. 2d 664 (Fla. 1993). Accordingly, the standard of review of the entry of summary judgment is de novo. 1000 Friends of Florida, Inc. v. Palm Beach County, 69 So.3d 1123, 1125 (Fla. 4th DCA 2011) [36 Fla. L. Weekly D2209a]. Additionally, if the benefits judgment is reversed, the fee judgment must also be reversed. See Hart v. Bankers Fire and Cas. Co., 320 So. 2d 485 (Fla. 4th DCA 1975).
In support of its appeal, UAIC argues that: ‘(1) the trial court misapplied the deductible by applying it to 80% of the amount billed by Stand Up MRI (“Stand Up”) rather than 80% of the amount that Stand Up accepted as payment in full; and (2) reversal of the benefits judgment requires reversal of the attorney’s fees judgment.
UAIC argues that the trial court’s ruling violated the meaning and purpose of the PIP deductible statute, section 627.739(2), Florida Statutes (2002). UAIC explains that the purpose of a deductible is to alter the point at which an insurance company’s obligation to pay will ripen. Therefore, as a preliminary matter, the insurer must first determine whether the amount billed is compensable under the insurance policy. UAIC argues that section 627.739(2), Florida Statutes requires the deductible to be subtracted from eighty percent of the medical expenses. UAIC argues that since section 627.739(2), Florida Statutes includes the words, “benefits otherwise due”, the Legislature intended for the deductible to be deducted from 80% of the amount of bills compensable under the statute. Therefore, when Stand Up settled its $1,219 bill for $600, the discharged $619 was no longer “benefits otherwise due”.
In response, Riverside argues that the trial court did not err in applying the entire bill from Stand Up. Riverside argues that for a PIP insurer to delay payments of other benefits upon which determination of deductible is necessary defeats the idea behind swift payment of PIP benefits. See Ivey v. Allstate Ins. Co., 774 So. 2d 679, 683-4 (Fla. 2000) [25 Fla. L. Weekly S1103a]. In support, Riverside proffers that Florida law is clear that an amount billed to a PIP insurer “is applied to the deductible within 30 days of the bill being received and cannot be unapplied.” See Weinstein v. United Auto. Ins. Co., 18 Fla. L. Weekly Supp. 480b (Fla. 17th Judicial Circuit, 2011).
This Court agrees, that the purpose of the PIP statute is to settle as many claims as possible, reasoning that the statute provides “swift and virtually automatic payment so that the injured insured may get on with his life without undue financial interruption.” Allstate Ins. Co. v. Holy Cross Hosp., Inc., 961 So. 2d 328, 332 (Fla. 2007) [32 Fla. L. Weekly S453a] (quoting Ivey v. Allstate Ins. Co., 774 So. 2d 679, 683-4 (Fla. 2000)). In order for a claim to be compensable, it must be reasonable, related, and medically necessary (“RRN”). See § 627.736(1), Fla. Stat. Additionally, the claims must be timely and not fraudulent. See Id.
Despite the clear purpose of the PIP statute, claims need not be applied to the deductible within 30 days as long as there is a “reasonable basis” for denying the claim. See UAIC v. A 1st Choice Healthcare Sys., 21 So. 3d 124 (Fla. 3d DCA 2009) [34 Fla. L. Weekly D2268a] (providing that an insurer may deny a PIP claim in whole or in part either before or after that claim becomes overdue provided it has “reasonable proof” that it is not responsible for payment). Meritorious, undisputed PIP claims should be paid in accordance with the clear purpose that the Florida legislature had in mind. However, there is no premise in case law or contract precluding the insurer from asserting defenses to avoid payment of the medical bills as long as there exists a “reasonable basis” for their denial. In the instant case, UAIC, the insurer, denied the claims based on a coverage investigation regarding alleged material misrepresentations made by Burke in her insurance application.
This Court distinguishes Weinstein from the instant case in that in Weinstein, the medical bills were never denied but rather, applied to the claimant’s deductible. Here, the medical bills were denied based on a coverage investigation. Thus, at the time Riverside submitted its medical bills, there was a reasonable basis for UAIC not to apply the deductible to the policy. However, following adjudication, when .the trial court determined that UAIC’s defenses were not meritorious, UAIC properly applied the bills and determined that the costs were within the deductible and thus, UAIC’s obligation to pay had not ripened. Accordingly, it is hereby
ORDERED and ADJUDGED that final summary judgment in favor of Riverside in the amount of $94.42 is REVERSED. It is further ORDERED that the award of attorney’s fees in favor of Riverside is REVERSED.
It is further ORDERED that Riverside’s cross appeal is DISMISSED.
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1This Court finds no inconsistency with its order entered on June 18, 2012 denying UAIC’s motion to dismiss Riverside’s cross appeal for lack of jurisdiction. The June 18, 2012 order addressed only the timeliness of Riverside’s cross-appeal and did not address whether this court could properly review the merits of such cross appeal.
2Both Article V, section 5(b), Florida Constitution and Florida Rule of Appellate Procedure 9.030(c)(1)(B) provide that the appellate jurisdiction of circuit courts is prescribed by general law. Art. V, § 5(b), and Fla. R. App. P. 9.030(c)(1)(B). Thus, the appellate jurisdiction of circuit courts is established solely by general law as enacted by the legislature and not by Florida Rule of Appellate Procedure 9.130. See Fla. R. App. P. 9.130 (a)(1) (2011) (“This rule applies to appeals to district court of appeal of the non-final orders authorized herein and to appeals to circuit court of non-final orders when provided by general law”), and Blore v. Fierro, 636 So. 2d 1329, 1331 (Fla. 1994).
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