22 Fla. L. Weekly Supp. 445a
Online Reference: FLWSUPP 2204EASTInsurance — Personal injury protection — Coverage — Emergency medical condition — Under amendments to PIP statute requiring PIP insurer to pay benefits up to $10,000 if qualified medical provider has determined that claimant had emergency medical condition and limiting reimbursement to $2,500 if qualified provider has determined that claimant did not have emergency medical condition, insurer properly limited benefits to $2,500 where qualified provider has not determined that insured suffered emergency medical condition — No merit to argument that insurer was required to pay benefits up to $10,000 unless there was determination of absence of emergency medical condition — Where insurer’s explanation of reimbursement requested additional information regarding existence of emergency medical condition to warrant payment of any additional benefits, request for information tolled time for payment of claim, and claim was not overdue when demand letter was sent — Question certified
L.LEE SMITH, D.C., P.A., (as assignee of PETRINA EASTON), Plaintiff, v. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 502014CC005325XXXXSB, Division RS. October 21, 2014. Edward A. Garrison, Judge. Counsel: Scott W. Dutton, Dutton Law Group, Miami, for Defendant.ORDER GRANTING FINAL SUMMARY JUDGMENTFOR DEFENDANT AND CERTIFICATE OF QUESTIONOF GREAT PUBLIC IMPORTANCE
This matter came on to be heard on October 9, 2014 on the Defendant, USAA Casualty Insurance Company’s, Motion for Summary Judgment regarding the Determination of an Emergency Medical Condition, Plaintiff’s Failure to Respond to Statutory Request for Information, and Plaintiff’s Premature Demand Letter and, after hearing argument of counsel, the Court makes the following findings of fact and conclusions of law.FACTS
This action involves a claim for personal injury protection medical benefits filed by the L. Lee Smith, D.C., P.A., (hereinafter as “Plaintiff”) as assignee of Petrina Easton (hereinafter “Claimant”) against the Defendant, USAA Casualty Insurance Company (hereinafter “Defendant”), arising out of a motor-vehicle accident that occurred September 15, 2013. At the time of the accident, the claimant was covered under a contract of insurance issued by the Defendant (hereinafter “the Policy”) that provided PIP benefits in accordance with the Florida Motor Vehicle No-Fault Law, as amended in 2013.
Following the accident the claimant sought treatment from various medical providers for injuries sustained as a result of the accident, and the Defendant received charges for medical benefit reimbursement. Among the charges received by the Defendant were charges from the Plaintiff for medical services rendered. The Defendant reviewed and adjusted the charges received in accordance with the terms of the Policy and the applicable provisions of the No-Fault-Law. To that end, it limited the reimbursement to $2,500.00 because the medical records received by it did not show that a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464 had determined that the claimant had an emergency medical condition as statutorily required for additional reimbursement.
For the Plaintiff’s charges above the limit of $2,500.00, the Defendant issued Explanations of Reimbursement that stated, “pursuant to section 627.736(1)(a)(4), Fla. Stat., $2,500.00 has been reimbursed. In order to make any additional reimbursement decisions, please provide the determination of the patient’s emergency medical condition by a provider authorized in section 627.736(1)(a)(3)-(4), Fla. Stat. This is a written request pursuant to F. S. A. 627.736(6)(b).” The Plaintiff did not respond to this request for information.
Without submitting the requested information, the Plaintiff sent two pre-suit “demand letters” pursuant to § 627.736(10), Fla. Stat. for additional payment related to its treatment of the claimant. The Defendant responded to the pre-suit demands stating that pursuant to §627.736(1)(a)(4), $2500 has been paid. Defendant also stated that in order to make any additional reimbursement decisions, documentation is needed regarding the determination of the patient’s emergency medical condition. Plaintiff did not provide to Defendant any documentation regarding the patient’s emergency medical condition.
The Plaintiff contends that a determination for an emergency medical condition is not required to obtain benefits up to $10,000 and therefore the requests in the Explanations of Reimbursement pursuant to 627.736(6)(b) are inapplicable. The Plaintiff also argues that under the applicable version of the No-Fault Law, medical benefits automatically default to $10,000 unless a treating physician determines that the injured person did not have an emergency medical condition.CONCLUSIONS OF LAW
All of the foregoing facts are uncontested. Therefore, the issues before this Court are pure matters of law. This Court agrees with the positions taken by the Defendant on all issues and therefore deems summary judgment in favor of the Defendant appropriate.
At the heart of the parties’ dispute is the interpretation of sections 627.736(1)(a)(3)-(4), Fla. Stat. The issue is whether under the provisions of the Florida No-Fault Law, as amended in 2012, reimbursement is limited to $2500 unless an authorized physician certifies that an emergency medical condition exists, as Defendant contends, or whether reimbursement automatically defaults to $10,000 unless a treating provider establishes that the claimant did not suffer an emergency medical condition. The Court finds that the provisions of the Florida Motor Vehicle No-Fault Law that the Defendant properly limited benefits to $2500 because there was no determination that the claimant suffered an “emergency medical condition” and that the Plaintiff’s claim for benefits prior to that determination was not overdue or ripe for pursuit in litigation.
Moreover, in the Defendant’s Explanation of Reimbursement for the Plaintiff’s charges at issue the Defendant clearly notified the Plaintiff that the statutory policy limits of $2,500.00 had been paid, and requested the Plaintiff to provide information regarding the determination of the claimant’s emergency medical condition by a medical provider authorized or qualified in section 627.736(1)(a)(3), Fla. Stat. in order to justify any additional reimbursement. The Court deems that the statement contained within the Explanation of Reimbursement is a request for information pursuant section 627.736(6)(b), Fla. Stat regarding the history, condition, treatment, dates, and costs of treatment. As such, the statement tolls the time when charges are due or overdue. See Professional Med. Group, Inc. v. Progressive Express Ins. Co., 13 Fla. L. Weekly Supp. 1000b (Miami-Dade Cty. Ct. Jul. 11, 2006) (King, J.); Wellington Chiropractic Center of Palm Beach, Inc. v. Nationwide Mutual Ins. Co., 11 Fla. L. Weekly Supp. 929b (Palm Beach Cty. Ct. Aug. 3, 2004) (Evans, J.).
The Defendant’s Explanations of Reimbursement clearly states that in order for the Defendant to make additional reimbursement decisions above the statutory $2500 reimbursement limit that the Plaintiff needed to provide a determination of the claimant’s emergency medical condition by a provider authorized by statute.
Finally, regarding the Defendant’s position that the plaintiff’s pre-suit demand letter was premature, a demand letter “may not be sent until the claim is overdue.” § 627.736(10)(a) (2013), Fla. Stat. Plaintiff’s demand letter was sent before the claim became overdue under § 627.736(1)(a)(3)-(4) (2013), Fla. Stat., and § 627.736(6)(b), Fla. Stat., and thus was premature. The lawsuit was premature and should not have been filed at all. See U.S. Security Ins. Co. v. TMJ Testing, Inc., 13 Fla. L. Weekly Supp. 862a (13th Jud. Cir. (App.) Apr. 12, 2006); USAA Cas. Ins. Co. v. American MRI, LLC, 19 Fla. L. Weekly Supp. 534a (11th Cir. Ct. (App.) Mar. 19, 2012).CERTIFICATE OF QUESTION OF GREATPUBLIC IMPORTANCE
At the conclusion of the hearing this Court granted the Defendant’s motion for summary judgment. Upon hearing the Court’s ruling counsel for the Plaintiff requested this Court to certify to the District Court of Appeal the issues presented as one of great public importance. Counsel for the Defendant did not object. However, prior to the preparation of this order counsel for the Plaintiff changed his mind and now objects to this certification. Nevertheless, this Court is of the opinion that the question of whether a certification of an emergency medical condition as prescribed in § 627.736(1)(a)(3) (2013) is required before PIP benefits over $2500.00 become available is a question of great public importance under Fla. R. App. P 9.030(b)(4)(A) and Fla. R. App. P. 9.160, and should be reviewed by the Fourth District Court of Appeal. While this Court has determined that such a certification is required, no District Court of Appeal has addressed this question.
At this time, hundreds of cases are pending before the county courts, circuit courts, and even the federal courts regarding the proper interpretation of the recently enacted amendments to the Florida No-Fault Law, including specifically § 627.736(1)(a)(3)-(4), Fla. Stat. (2013). There is great doubt as to the requirements of the statute in determining when payment above the $2500.00 cap for non-emergency medical conditions is required. Multiple repetitious litigations will continue absent controlling precedent, and leave great uncertainty in the law on this subject.
Therefore, this Court certifies the following question to the Court of Appeal for the Fourth District as being of great public importance:
IN AN ACTION BY AN ASSIGNEE FOR NO-FAULT INSURANCE BENEFITS UNDER A POLICY OF MOTOR VEHICLE INSURANCE, ARE BENEFITS ABOVE $2500.00 ONLY AVAILABLE WHERE THERE HAS BEEN A CERTIFICATION BY A MEDICAL PROVIDER AUTHORIZED BY STATUTE THAT AN EMERGENCY MEDICAL CONDITION EXISTS, AS DEFINED IN THE FLORIDA NO-FAULT LAW?
This Court respectfully requests that the District Court of Appeal Answer this question.
It is therefore
ORDERED AND ADJUDGED that the Defendant’s Motion for Final Summary Judgment against the Plaintiff, be and hereby is, GRANTED and DEFENDANT SHALL GO HENCE WITHOUT DAY. The Court reserves jurisdiction to determine the entitlement and amount of fees and costs to the Defendant as well as to any and other further relief as the Court deems just and proper.
The Court CERTIFIES THE QUESTION stated above AS BEING OF GREAT PUBLIC IMPORTANCE and requests that the District Court of Appeal accept jurisdiction of the certified question.
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