22 Fla. L. Weekly Supp. 164a
Online Reference: FLWSUPP 2201PELLInsurance — Personal injury protection — Coverage — Emergency services — Deductible — Because insurer is mandated by statute to reserve $5,000 for emergency service providers, insurer should not have applied claim by plaintiff provider within that classification to deductible
EMERGENCY PHYSICIANS OF CENTRAL FLORIDA, LLP, as assignee of Abigail Pelletier, Plaintiff, v. METROPOLITAN CASUALTY INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 2011-SC-002172. June 26, 2014. Jerri L. Collins, Judge. Counsel: Mark A. Cederberg, Bradford Cederberg P.A., Orlando, for Plaintiff. Michael M. Bell, Orlando, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTIONFOR FINAL SUMMARY JUDGMENT ANDDENYING DEFENDANT’S MOTION FORSUMMARY FINAL JUDGMENT
THIS MATTER having come before this Honorable Court on May 28, 2014 on Plaintiff’s Motion for Final Summary Judgment and Defendant’s Amended Motion for Summary Final Judgment and this Honorable Court having heard arguments of counsel, reviewed the evidence, relevant Florida statutes and case law presented and being otherwise fully advised in the premises, makes the following findings:Factual Background
This case presents with facts that are not in dispute. The Defendant, Metropolitan Casualty Insurance Company (“Metropolitan”) issued a policy of insurance in favor of its assignor, Abigail Pelletier, which provided $10,000.00 in Personal Injury Protection Benefits with a $500.00 deductible and $5,000.00 in Medical Payments coverage. Ms. Pelletier was involved in a motor vehicle accident on June 16, 2011 in which she sought treatment from various health care providers including the Plaintiff in this matter, Emergency Physicians of Central Florida (“EPCF”). EPCF is a group of physicians licensed under chapter 458 and/or chapter 459 who provide emergency services and care as defined in Florida Statute 395.002(9) as referenced in Florida Statute 627.736(4)(c).
Upon being placed on notice of this accident on June 16, 2011, Metropolitan opened a PIP claim and began processing bills. The first bill received by Metropolitan was from Orlando Health (hospital) on June 30, 2011 in the amount of $190.00 for date of service June 16, 2011. Metropolitan reduced this charge to $142.50 and applied $142.50 to the insured’s $500.00 deductible. The second bill received by Metropolitan was from EPCF on July 5, 2011, for emergency services and care provided to Ms. Pelletier on June 16, 2011, in the amount of $287.00. This bill was received by Metropolitan within 30 days’ notice of the loss. Metropolitan allowed the full amount of EPCF’s bill and applied EPCF’s full charge of $287.00 to the insured’s deductible. The third bill received by Metropolitan was from Health Central Paramedics (ambulance) on July 8, 2011 in the amount of $659.00 for date of service June 16, 2011. Metropolitan reduced this charge to $652.44 and applied the remainder of the deductible to this bill. The parties disagree whether Metropolitan’s application of EPCF’s bill to the deductible was proper. Metropolitan contends that it was proper, based on the fact that EPCF’s bill was the second bill received and some of the deductible still remained. EPCF contends that it was not proper on the basis that EPCF is a protected provider under Fla. Stat. 627.736(4)(c) and its bills are to be paid out of the $5000.00 reserve of PIP benefits created for 4(c) providers, once the deductible is otherwise satisfied by non-protected providers’ bills (i.e. the bills from Orlando Health and Health Central Paramedics in this case). The Court agrees with EPCF and grants Plaintiff’s Motion for Final Summary Judgment and denies Defendant’s Amended Motion for Summary Final Judgment.Conclusions of Law and Ruling
The legal issue presented is whether Metropolitan was required to reserve EPCF’s bill for payment pursuant to Fla. Stat. 627.736(4)(c) when EPCF timely submitted its bill for payment, and otherwise complied with the requirements set forth in Fla. Stat. 627.736(4)(c) which creates a mandatory reserve for payment of PIP benefits, versus applying EPCF’s bill to the PIP deductible. The Court finds that, pursuant to Fla. Stat. 627.736(4)(c), EPCF’s bill should have been paid from Ms. Pelletier’s PIP benefits under the $5,000 reserve (and therefore should not have been applied to the deductible).
On January 1, 2008, the Florida legislature enacted a revised PIP statute which created a mandatory set-aside of $5,000.00 of the $10,000.00 in PIP benefits, for the payment of bills submitted by a special class of provider within a particular time frame. Florida Statute §627.736(4)(c) states:
Upon receiving notice of an accident that is potentially covered by personal injury protection benefits, the insurer must reserve $5,000 of personal injury protection benefits for payment to physicians licensed under chapter 458 or chapter 459 or dentists licensed under chapter 466 who provide emergency services and care, as defined in s. 395.002(9), or who provide hospital inpatient care. The amount required to be held in reserve may be used only to pay claims from such physicians or dentists until 30 days after the date the insurer receives notice of the accident. After the 30-day period, any amount of the reserve for which the insurer has not received notice of a claim from a physician or dentist who provided emergency services and care or who provided hospital inpatient care may then be used by the insurer to pay other claims. The time periods specified in paragraph (b) for required payment of personal injury protection benefits shall be tolled for the period of time that an insurer is required by this paragraph to hold payment of a claim that is not from a physician or dentist who provided emergency services and care or who provided hospital inpatient care to the extent that the personal injury protection benefits not held in reserve are insufficient to pay the claim. This paragraph does not require an insurer to establish a claim reserve for insurance accounting purposes. (Emphasis added.)
An examination of (4)(c), which is part of the insurance contract at issue as PIP is statutorily mandated insurance, reveals that upon notice of an accident potentially covered by PIP, an insurer must create a mandatory reserve which may only be used to pay certain protected providers. In order to qualify for (4)(c) protection, have a priority claim for payment without application of any deductible, and take advantage of the mandatory reserve, a (4)(c) provider’s claim must be received by the PIP insurer within 30 days of the insurer receiving notice of the accident. Applying the above to the facts of the case before this Court, it is apparent that Plaintiff (EPCF) timely submitted a qualifying protected claim for emergency services and care under (4)(c) and that claim was received by Defendant (Metropolitan) within 30 days of Metropolitan receiving notice of the accident. Thus, EPCF satisfied the 30 day notice requirement of section (4)(c). The qualifying protected (4)(c) claim submitted by EPCF and received by Metropolitan was for $287.00. Accordingly, 80% of $287.00, or $229.60, was required to be held and maintained in the mandatory reserve and was only available to pay EPCF’s claim. Upon exhaustion of the deductible by non-qualifying providers’ bills, Metropolitan was required to pay this amount under the insured’s PIP coverage to EPCF. Metropolitan failed to do so.
In reaching its decision in this case, the Court makes specific note of the fact that Fla. Stat. §627.739 was amended in 2003, followed by amendment in 2008 to Fla. Stat. §627.736 to add subsection (4)(c). This Court believes that the subsequent amendment of Fla. Stat. §627.736(4)(c) demonstrates the Legislature’s intent to provide an additional level of protection for emergency care providers, thus ensuring payment of their invoices/bills. The Plaintiff complied with the conditions of subsection (4)(c), thereby qualifying as a member of the protected class, and yet its bill went unpaid because it was applied to the deductible. It is illogical to suggest that the Florida Legislature created a special class, provided for a special fund to be set aside and reserved for payment of PIP benefits to that special class, set a specific time frame during which the special class member is to submit qualifying invoices/bills then penalize the special class member for the timely submission of its claim by allowing it to be applied to the deductible.
In conclusion, this Court agrees with EPCF and grants Plaintiff’s Motion for Final Summary Judgment and denies Defendant’s Amended Motion for Summary Final Judgment. By so ruling, this Court finds that PIP insurers are required to reserve $5,000 of the PIP benefits exclusively for payment to the protected class defined in Fla. Stat. §627.736(4)(c) and that the $5,000 reserve may be used only to pay the claims of the protected class of providers who timely submit their claim(s), and may not apply the amount of such claim(s) to any PIP deductible. The Court finds that the deductible must be satisfied by application of the invoices/bills submitted to the insurer by non-protected providers, and upon satisfaction of the deductible in such manner, then the protected provider is entitled to have its invoice/bill paid.
Accordingly, it is ORDERED AND ADJUDGED that:
Plaintiff’s Motion for Final Summary Judgment is hereby GRANTED and Defendant’s Amended Motion for Summary Final Judgment is hereby DENIED.
The Plaintiff is entitled to recover from Defendant $229.60 (80% of $287.00) plus accrued interest in the amount of $40.23 (6% interest from July 5, 2011) for a total of $269.83 for which let execution issue forthwith. Post judgment interest of 4.75% per annum shall be due on this judgment pursuant to Fla. Stat. §55.03. The Court also finds that Plaintiff is hereby entitled to reasonable attorneys’ fees and costs and reserves jurisdiction to determine the amount.
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