22 Fla. L. Weekly Supp. 282b
Online Reference: FLWSUPP 2202GREEInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy that subjects payments to any and all limitations authorized by PIP statute, including all fee schedules, clearly and unambiguously elects to limit reimbursement to permissive statutory fee schedule
DR. ANTHONY STANGANELLI, as assignee of Deangelo Green, Plaintiff, vs. ALLSTATE INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 502013SC003186XXXXMB. November 21, 2013. Honorable Sandra Bosso-Pardo, Judge. Counsel: Stephen D. Deitsch, Deitsch & Wright, P.A., Lake Worth, for Plaintiff. Douglas G. Brehm, Shutts & Bowen LLP, Miami, for Defendant.
ORDER GRANTING ALLSTATE’S MOTION FORSUMMARY JUDGMENT AND DENYING PLAINTIFF’SMOTION FOR SUMMARY JUDGMENT
This matter came before the Court upon the parties’ Cross Motions for Summary Judgment. The Court, having heard argument of the Parties on November 15, 2013, and being otherwise duly advised in the matter, GRANTS Allstate’s Motion for Summary Judgment and DENIES Plaintiff’s Motion for Partial Summary Judgment. The Court finds and rules as follows:
1. Plaintiff’s Complaint challenges Allstate’s ability to limit reimbursements for medical services covered under the Personal Injury Protection (“PIP”) portion of Allstate’s policy of automobile insurance. Allstate contends that its policy specifically and expressly notifies its policyholder (as well as any assignee providers) that Allstate has elected to apply the fee schedule limitations to PIP reimbursements that are authorized under the No-Fault Statute.
2. The Court finds that Allstate’s policy language complies with the requirements set forth by the Florida Supreme Court and constitutes an enforceable election to apply the reimbursement limitations permitted under Fla. Stat. 627.736(5)(a)(2). The Court rejects Plaintiff’s contention that Allstate’s policy language is unclear and/or ambiguous.UNDISPUTED FACTS
3. The Parties entered into a Joint Stipulation of Facts, which has been filed with the Court, and which sets forth all material facts. As set forth more fully in the Joint Stipulation of Facts, the parties agree that: an automobile accident occurred; the claimant was injured in the accident; the claimant was covered under a valid Policy issued by Allstate; the claimant assigned to Plaintiff all rights to No-Fault benefits under the Policy; Plaintiff provided medical services to the claimant that were medically necessary and related to the subject accident; the medical services were covered under the No-Fault portions of the Policy; invoices for the medical services were sent by Plaintiff and received by Allstate; and Allstate issued reimbursement to Plaintiff for all services pursuant to the reimbursement provisions of Fla. Stat. §627.736(5)(a)(2)f. The Parties agree, and the Court finds, that there are no disputes as to any material facts in this case.
4. The relevant portion of Allstate’s policy provides:
In accordance with the Florida Motor Vehicle No-Fault Law, Allstate will pay to or on behalf of the injured person the following benefits. . .
1. Medical Expenses.
Eighty Percent of reasonable expenses for medically necessary medical, surgical, X-ray, dental and rehabilitative services. . .
. . . .
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.
CONCLUSIONS OF LAW
5. In GEICO Gen. Ins. Co. v. Virtual Imaging Services, 2013 WL 3332385 (Fla. No. SC12-905, July 3, 2013) [38 Fla. L. Weekly S517a], the Florida Supreme Court held: “We conclude that the insurer was required to give notice to its insured by electing the permissive Medicare fee schedules in its policy before taking advantage of the Medicare fee schedule methodology to limit reimbursements.”
6. Plaintiff contends that Allstate’s policy language does not constitute a valid election because the reimbursement limitation language in Allstate’s policy is not sufficiently clear and unambiguous.
7. Plaintiff contends that the policy is unclear because it states that it will pay “reasonable expenses” but also states that it will apply reimbursement “limitations.” Plaintiff argues that these provisions are contradictory or, at the very least, do not constitute a clear election of the payment calculation methodology that Allstate will use. The Court rejects this argument. There is nothing unclear. The policy contains a general coverage provision that complies with the coverage of reasonable medical expenses that is statutorily mandated by Fla. Stat. 627.736(1)(a). The policy then states that the reimbursement limitations permissible under the statute “shall” be applied in reimbursing the covered medical expenses.
8. The ambiguity arising from the Legislature’s use of the word “may” in section 5(a)(2) is clearly addressed by Allstate’s policy, which affirmatively states that statutorily authorized limitations to PIP benefit payments “shall” be applied and specifically mentions fee schedules. There is simply no question about what the terms of that contract provide. The Policy explains the scope of coverage provided (eighty percent of reasonable medical expenses) and the limitations on reimbursements for covered services (“amounts payable shall be subject to all limitations authorized by Fla. Stat. § 627.736 . . . including, but not limited to, all fee schedules”).
9. Additionally, Plaintiff contends that Allstate’s policy language is problematic because it only cites to Fla. Stat. 627.736, rather than providing a pinpoint citation to Fla. Stat. 627.736(5)(a)(2). The Court rejects this argument. Fla. Stat. 627.736 contains only one reimbursement limitation section — subsection 5(a)(2). There is no ambiguity.
10. The Court finds that Allstate’s policy made a clear and unambiguous election to apply the reimbursement limitations permissible under 627.736(5)(a)(2), which includes the Medicare Part B Fee Schedules applicable to the medical services at issue in this case. The Court finds that Allstate’s policy language complies with the requirements set forth by the Florida Supreme Court in Virtual Imaging. Allstate affirmatively and expressly adopted the fee schedule limitations that the Legislature had authorized. It issued a policy that affirmatively informed its insureds that PIP benefits under that policy would be limited as authorized by the Florida No-Fault statute, including all fee schedules.
Accordingly, Allstate’s Motion for Summary Judgment is GRANTED, and Plaintiff’s Motion for Summary Judgment is DENIED. Final Judgment is entered in favor of Allstate. Plaintiff shall take nothing by this action, and Defendant shall go hence without day.
