22 Fla. L. Weekly Supp. 279a
Online Reference: FLWSUPP 2202CSANInsurance — 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 until there was determination that insured had 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 — Claim for benefits in excess of $2,500 was not overdue or ripe for litigation prior to determination that insured suffered emergency medical condition — Because suit filed before insurer provided determination of emergency medical condition was premature, insurer’s post-suit payment of benefits upon receipt of that determination was not confession of judgment entitling medical provider to award of attorney’s fees and costs — Question certified
MEDICAL CENTER OF THE PALM BEACHES D/B/A CENTRAL PALM BEACH PHYSICIANS & URGENT CARE, INC. A/A/O CARMEN SANTIAGO, Plaintiff, v. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 502013SC012523XXXXMB. August 20, 2014. Sandra Bosso-Bardo, Judge. Counsel: Gorden & Donner, P.A., Pam Beach Gardens, for Plaintiff. Scott W. Dutton, Dutton Law Group, Miami, for Defendant.
AFFIRMED. 41 Fla. L. Weekly D2018b (Medical Center of the Palm Beaches v. USAA Casualty Ins. Co., 4D14-3580, 8-31-2016)
ORDER GRANTING FINAL SUMMARY JUDGMENTFOR DEFENDANT AND CERTIFICATE OF QUESTIONOF GREAT PUBLIC IMPORTANCE
This matter came on to be heard on July 15, 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 Plaintiff, Medical Center of the Palm Beaches, doing business as Central Palm Beach Physicians & Urgent Care, Inc. (hereinafter as “Plaintiff”) as assignee of Carmen Santiago (hereinafter “Claimant”) against the Defendant, USAA Casualty Insurance Company (hereinafter “Defendant”), arising out of a motor-vehicle accident that occurred May 15, 2013. At the time of the accident, the claimant was covered under a contract of insurance issued by the Defendant that provided PIP benefits in accordance with the Florida Motor Vehicle No-Fault Law, as amended in 2012, for the policy period beginning March 22, 2013 (hereinafter “the Policy”).
Following the accident the claimant sought treatment from various medical providers for injuries sustained as a result of the accident, and the Defendant received bills for medical benefit reimbursement. Among the bills received by the Defendant were bills from the Plaintiff for services rendered from June 28, 2013 to July 24, 2013. The Defendant reviewed and adjusted the bills 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.” The Plaintiff did not respond to this request for information.
Without submitting the requested information, the Plaintiff sent a pre-suit “demand letter” pursuant to § 627.736(10), Fla. Stat. for additional payment related to its treatment of the claimant. The Defendant responded to the pre-suit demand and reiterated that pursuant to § 627.736(1)(a)(3), Fla. Stat., $2,500.00 had been paid pursuant to the policy. In also requested the Plaintiff to provide the determination of the claimant’s emergency medical condition by an authorized provider in order to make any additional reimbursement decisions. The Plaintiff did not respond to this request for information.
The Plaintiff filed the subject lawsuit on November 6, 2013. On November 18, 2013, after suit was filed, the Defendant received written notice from another authorized medical provider that the claimant had an emergency medical condition. The Plaintiff never provided a response to the Defendant’s § 627.736(6)(b), Fla. Stat. request for information. However, after receiving written notice of the emergency medical determination by an authorized provider, payment of medical benefits was timely issued by the Defendant on November 27, 2013.
Despite such payment by the Defendant, the Plaintiff pursued this lawsuit to recover damages and attorney’s fees and costs. The Plaintiff contends that the Defendant’s request for information contained within the Explanations of Reimbursement did not make specific reference to section 627.736(6)(b), Fla. Stat. It also contends that it is insufficient that the section 627.736(6)(b), Fla. Stat. request for information is contained within the Explanations of Reimbursement. Rather the Plaintiff suggests to the Court that a separate and distinct section 627.736(6)(b), Fla. Stat. is letter required. The plaintiff also argues that under the current 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.
Finally, the Plaintiff contends that the Defendant’s post suit payment necessarily results in a confession of judgment by payment entitling it to attorney’s fees and costs.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 require that the Defendant’s adjustment of the subject case properly limited benefits to $2500 until there was a 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.
In order to make the statutory intent workable, the statute must be interpreted to require the provider to provide the insurer with a determination that an emergency medical condition actually exists before the insurer may be liable for payment of medical benefits in excess of $2,500.00. To do otherwise would be to defeat the statutory intent to limit PIP payments, and would in effect continue to make $10,000.00 in benefits available on any claim, unless a treating provider notified the insurer that the claimant had NOT suffered an emergency medical condition. In practice, this would seldom, if ever, take place, and would defeat the purpose of the 2012 amendments recently enacted.
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 this 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.
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. The fact that the Explanations of Reimbursement do not specifically reference § 627.736(6)(6), Fla. Stat. or the fact that the request is not contained within a separate or distinct letter is irrelevant. That is not required by the statute. Moreover, the request for information could not be clearer. In fact, if the request for information had just cited § 627.736(6)(b), Fla. Stat., it would be less clear than spelling out what information the Defendant required to make additional payments. To this Court, the Defendant’s request for information is abundantly clear as to what it was looking for and why it was not paying above the $2500 reimbursement limit.
The court also disagrees with the Plaintiff’s interpretation that the Defendant has to provide a letter or medical determination from the treating physician that the plaintiff did not have an emergency medical condition or else payment defaults to $10,000 in medical benefits. It is clear from the statutory structure that up to $10,000 of medical benefits only becomes available if the injured person had an emergency medical condition.
Finally, this Court disagrees that there has been a waiver of the forgoing defenses by the Defendant because it paid after suit was filed. There has been no confession of judgment, because payment of benefits was not wrongfully withheld. In fact, payment was timely made after Defendant received written notice of a covered loss in the form of an emergency medical determination by an authorized physician.
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. Because the lawsuit was premature and should not have been filed at all, Plaintiff cannot be entitled to fees and costs, as § 627.428, Fla. Stat. (2013) does not apply to its lawsuit. The confession of judgment doctrine only “applies where the insurer has denied benefits the insured was entitled to, forcing the insured to file suit, resulting in the insurer’s change of heart and payment before judgment,” Clifton v. United Cas. Ins. Co. of Am., 31 So. 3d 826, 829 (Fla. 2d DCA 2010) [35 Fla. L. Weekly D364e] rev. denied, 49 So. 3d 746 (Fla. 2010); State Farm Florida Ins. Co. v. Lorenzo, 969 So. 2d 393, 397 (Fla. 5th DCA 2007) [32 Fla. L. Weekly D1791e].
CERTIFICATE OF QUESTION OF GREATPUBLIC IMPORTANCE
After hearing argument of counsel, 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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