20 Fla. L. Weekly Supp. 883a
Online Reference: FLWSUPP 2009VSOLInsurance — Personal injury protection — Coverage — Medical expenses — MRI — Accident occurring during statutory gap period — County court erred in concluding that insurer correctly applied statute limiting amount MRI providers could charge to 200% of the allowable amount under Medicare Part B fee schedule where statute had been automatically repealed under “sunset” provisions at time of accident, policy provided for payment of 80% of reasonable and necessary medical expenses, and policy stated that in determining reasonableness, insurer would consider only the actual charge, the charge negotiated with a provider, or the charge determined by a statistically valid database — Language indicating insurer would pay in accordance with No-Fault Law was not sufficient to place insured on notice that insurer intended to pay less than 80% of reasonable fee as determined by factors specified in policy — Insurer had no vested right or legitimate expectation in continuing statutory fee limitations beyond repeal date stated in law’s sunset provision
WIDE OPEN MRI, INC., (Valerie Solomon), Appellant, vs. USAA CASUALTY COMPANY, Appellee. Circuit Court, 17th Judicial Circuit (Appellate) in and for Broward County. Case No. 10-027835 CACE (08). L.T. Case No. 08-011815 COCE (55). September 21, 2012.
[County court order published at 17 Fla. L. Weekly Supp. 394b]OPINION
(ROSS, Judge.) THIS CAUSE came before the Court, sitting in its appellate capacity, upon appeal by Appellant, Wide Open MRI, Inc. (“Wide Open”), of the trial court’s entry of final summary judgment in favor of Appellee, USAA Casualty Insurance Company (“USAA”). The Court, having considered the briefs filed by the parties and being duly advised in the premises, dispenses with oral argument and finds as follows:Facts
On June 6, 2007, USAA issued a policy providing personal injury protection benefits to Valerie Solomon (“Insured”) for policy period July 8, 2007 through January 8, 2008. The policy provided that USAA “will pay, in accordance with the Florida Motor Vehicle No-Fault Law,” eighty percent (80%) of medical benefits, defined as reasonable expenses for necessary medical services. (R. 330-331). The policy further stated that “[i]n determining what is reasonable, [USAA] will consider the following: 1) the actual charge, 2) the charge negotiated with a provider, or 3) the charge determined by a statistically valid database . . . .” (R. at 331).
The No-Fault Law in effect at the time the contract was executed required insurers to pay “[e]ighty percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services.” § 627.736(1)(a), Fla. Stat. (2007). Section 627.736(5)(b)(5) limited the amount MRI providers could charge for services rendered to “200 percent of the allowable amount under the participating physician fee schedule of Medicare Part B.” However, effective October 1, 2007, two months after the Solomon policy was issued, the entire No-Fault Law was automatically repealed by a “sunset” provision enacted as part of the 2003 amendments to the No Fault Law.1
On September 24, 2007, three months after the policy was issued and one month prior to the statute being repealed, the insured was injured in a motor vehicle accident. As a result, the insured received an MRI from Wide Open on November 26, 2007, approximately two months after the No Fault Act expired. The Insured assigned to Wide Open her PIP benefits under the USAA policy. Wide Open billed USAA $2,150.00 for the MRI. However, USAA applied the expired fee limitations set forth in section 627.736(5)(b)(5) and paid Wide Open a total of $1,131.40. On July 28, 2008, Wide Open filed suit in county court seeking monetary damages for the unpaid PIP benefits and declaratory relief regarding the parties’ rights and obligations under section 627.736(5)(b)(5), Florida Statutes (2007).
Both parties moved for summary judgment. On October 14, 2009, Plaintiff filed its motion for summary judgment arguing that § 627.736(5)(b)(5) did not apply to this claim. On November 23, 2009, USAA filed its motion for summary judgment arguing that: (1) it satisfied its obligation to Plaintiff by making payment pursuant to § 627.736(5)(b)(5) (2007); and (2) Wide Open had not submitted a statutorily compliant demand letter. USAA argued that its reimbursement obligation was limited by the statutory cap on charges for medical services because the fee schedule mandated by section 627.736(5)(b)(5) was incorporated into the contract by virtue of the policy language stating that USAA “will pay in accordance with the Florida Motor Vehicle No-Fault Law.” USAA asserted that, because the limits were incorporated into the policy before the statute was repealed, it was entitled to rely on that fee schedule when calculating the reimbursement owed to Wide Open for services rendered after the statute had been repealed. Wide Open did not file a response brief.
The county court entered summary judgment for USAA. In reaching its conclusion, the county court reasoned as follows:
In this case, USAA had an obligation to pay Valerie Solomon’s medical providers in accordance with the 2007 Florida Motor Vehicle No-Fault Law. The expectation and method of payment is a legally regarded part of the agreement by and between USAA and its insured. Because the laws in force at the time of the making of a contract enter into and form a part of the contract, the rights and obligations arising under cannot be affected by the PIP Statute’s expiration.
R. at 475. This appeal followed.Analysis
Matters of contractual and statutory interpretation are questions of law to be decided by the trial court. Borden v. E.-European Ins. Co., 921 So. 2d 587, 591 (Fla. 2006) [31 Fla. L. Weekly S34a]; McPhee v. The Paul Revere Life Ins. Co., 883 So. 2d 364, 367 (Fla. 4th DCA 2004) [29 Fla. L. Weekly D2174a]. “The standard of review governing a trial court’s ruling on a motion for summary judgment posing a pure question of law is de novo.” Major League Baseball v. Morsani, 790 So. 2d 1071, 1074 (Fla. 2001) [26 Fla. L. Weekly S465a]; Progressive Auto Pro Ins. Co. v. One Stop Med., Inc., 985 So. 2d 10, 12 (Fla. 4th DCA 2008) [33 Fla. L. Weekly D1174a].
Generally, when parties contract upon a matter which is the subject of statutory regulation, the existing statutory limitations and requirements become part of the contract and define the parties’ contractual rights and obligations toward one another. See Foundation Health v. Westside EKG Assocs., 944 So. 2d 188, 195 (Fla. 2006) [31 Fla. L. Weekly S669b]; Northbrook Prop. & Cas. Ins. Co. v. R & J Crane Serv., Inc., 765 So. 2d 836, 839 (Fla. 4th DCA 2000) [25 Fla. L. Weekly D1956a]. However, an insurer may provide greater coverage than is statutorily required. Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So. 3d 63, 68 (Fla. 4th DCA 2011) [36 Fla. L. Weekly D1062a]; Carguillo v. State Farm Mut. Auto. Ins. Co., 529 So. 2d 276, 278 (Fla. 1988); Sturgis v. Fortune Ins. Co., 475 So. 2d 1272, 1273-74 (Fla. 2d DCA 1985). Therefore, the scope and extent of insurance coverage is defined by the plain language and terms of the policy, not the statute. DCI MRI, Inc. v. Geico Indemn. Co., 79 So. 3d 840, 842 (Fla. 4th DCA 2012) [37 Fla. L. Weekly D170e] (citing Kingsway, 63 So. 3d at 68). Accordingly, statutory provisions that would restrict coverage to less than what is clearly stated in the policy will not be incorporated. Id. at 842; see also, Kingsway, 63 So. 3d at 68 (“[W]hen the insurance policy provides greater coverage than the amount required by statute, the terms of the policy will control.”); Wright, 739 So. 2d at 181 (“[T]he language of the policy, not the statute, determines the coverage provided . . . .”). “If an insurer intends to restrict coverage, it should use language clearly stating its purpose.” Ward v. Nationwide Mut. Fire Ins. Co., 364 So. 2d 73, 77 (Fla. 2d DCA 1978); see Garcia v. Fed. Ins. Co., 969 So. 2d 288, 290-92 (Fla. 2007) [32 Fla. L. Weekly S657a].
In this case, the PIP coverage (Part B-1) policy provided that USAA would pay eighty percent (80%) of reasonable medical expenses. (R. at 330-331). The trial court erred in relying on the definitions provided by the Medical Payments Coverage (Part B-2). (R. at 333-336). A review of the insurance policy reveals that the PIP coverage is separate and distinct from the Medical Payments coverage. Importantly, each policy provides its own insuring agreement and definitions. See Holloway v. State Farm Mut. Auto. Ins. Co., 370 So. 2d 452, 454 (Fla. 4th DCA 1979) (recognizing that PIP coverage is separate from Medical Payment Coverage). Here, the Plaintiff seeks payment under PIP coverage, and accordingly the trial court should apply the Insuring Agreement and definitions included in Part B-1.
The PIP coverage Insuring Agreement provides that USAA will pay “80% of medical benefits.” The policy does not state USAA would pay 80% of 200% of the Medicare Part B Schedule set forth in section 627.736(5)(b)(5). In addition, the policy does not state that USAA would consider the Medicare fee schedule when determining whether the amount charged for medical services constituted a reasonable expense. The policy plainly states that USAA would consider the following three factors: 1) the actual charge, 2) the charge negotiated with a provider, or 3) the charge determined by a statistically valid database. There is no record evidence that USAA negotiated a charge with Wide Open, and no record evidence that the charge was determined by a statistically valid database. Therefore, under the plain language of the contract, “the actual charge” was a reasonable expense which USAA agreed to pay.
The language indicating that USAA would “pay, in accordance with the Florida Motor Vehicle No-Fault Law” was insufficient to place the insured on notice that USAA intended to pay less than 80% of the actual charge as stated in the policy. See DCI MRI, Inc., 79 So. 3d at 842; see also, Ward, 364 So. 2d at 77; Wright, 739 So. 2d at 181 (policy stating the insurer “will pay, in accordance with the No-Fault Law” not construed to limit coverage to the minimum amount required by law). Because incorporating the statutory fee limitations would reduce the amount USAA would pay for medical services to less than the amount stated in the policy, section 627.736(5)(b)(5) was not incorporated into the policy even though it existed at the time the contract was executed. As a result, USAA had no contractual right to the statutory fee limitations.
Furthermore, USAA had no vested right or legitimate expectation in continuing the fee limitations beyond October 1, 2007. Vested rights generally arise where a party has taken detrimental action in reasonable reliance on the state of the law prior to a legislative change. See Doe v. America Online, Inc., 718 So. 2d 385, 388 (Fla. 4th DCA 1998) [23 Fla. L. Weekly D2314a]. In this case, the event that triggered the No-Fault Law’s automatic repeal occurred long before USAA issued the subject policy. Therefore, USAA knew that the No-Fault Law and its limitations would cease to exist shortly after this policy went into effect. However, USAA did nothing to protect itself against the repeal of the statute. Although USAA asserted that it had a vested right to the fee limitations, it failed to establish the elements necessary to prove the existence of a vested right. See Coventry First, LLC v. State, Office of Ins. Reg., 30 So. 3d 552, 558 (Fla. 1st DCA 2010) [35 Fla. L. Weekly D383a] (“A vested right must be ‘more than a mere expectation based on an anticipation of the continuance of an existing law; it must have become a title, legal or equitable, to the present or future enforcement of a demand.’ ” (quoting Div. of Workers’ Comp. v. Brevda, 420 So. 2d 887, 891 (Fla. 1st DCA 1982))). Consequently, the amount Wide Open could charge for its services was controlled by the date the services were rendered, not the date the contract was executed. Because the statutory limitations were not in effect at the time the MRI was performed, the county court erred in concluding that USAA “correctly applied the fee schedule set forth in Florida Statute § 627.736(5)(b)5 to the Plaintiff’s charges.”
Accordingly, it is hereby
ORDERED AND ADJUDGED that the county court’s final judgment is REVERSED and REMANDED for proceedings consistent with this Opinion.
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1The “sunset” provision stated the following:
Effective October 1, 2007, sections 627.730, 627.731, 627.732, 627.733, 627.734, 627.736, 627.737, 627.739, 627.7401, 627.7403, and 627.7405, Florida Statutes, constituting the Florida Motor Vehicle No-Fault Law, are repealed, unless reenacted by the Legislature during the 2006 Regular Session and such reenactment becomes law to take effect for policies issued or renewed on or after October 1, 2006.
Ch. 2003-411, §19, Laws of Fla. (2003).
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