22 Fla. L. Weekly Supp. 281a
Online Reference: FLWSUPP 2202MANTInsurance — 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
PALM BEACH PAIN INSTITUTE, INC., as assignee of Abraham Mantin, Plaintiff, vs. ALLSTATE PROPERTY AND CASUALTY INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 502012SC020793XXXXMB. August 21, 2013. Sandra Bosso-Pardo, Judge. Counsel: Daniel A. Norton, Kogan & DiSalvo, P.A., Boynton Beach, 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 August 7, 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 agree that instant case involves no disputed facts. Allstate’s insured, Abraham Mantin, was involved in an automobile accident in May 2009. Mantin sustained injuries that were covered under Allstate’s policy and the corresponding provisions of Fla. Stat. 627.736 (2008). Pursuant to a valid assignment of benefits, Plaintiff, Palm Beach Pain Institute, provided medical services to Mantin. These medical services were reasonable, related and necessary and otherwise covered under Allstate’s policy. Allstate reimbursed all invoices received from Plaintiff relating to this claim pursuant to the Medicare Part B Participating Physicians Fee Schedule.
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 Fla. Stat. § 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. Plaintiff advances four arguments in support of its position.
7. First, 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. Second, 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. Third, Plaintiff contends that Allstate’s policy language is insufficient because it only vaguely references “all fee schedules,” rather than more specifically citing the Medicare Part B Participating Physicians Fee Schedule. The Court rejects this argument as well. Allstate’s policy language encompasses all of reimbursement limitations authorized by subsection 5(a)(2)(a-f), not just the Medicare fee schedules. Where a contract of insurance is entered into on matters surrounded by statutory limitations and requirements, the parties are presumed to have entered into such agreement with reference to statute. Weldon v. All American Ins. Co., 605 So. 2d 911 (Fla. 2d DCA 1992). There is no ambiguity within the statute as to which limitation of liability, (i.e. which of the subsections, (a)-(f)) will apply to a given medical procedure. Each limitation applies to its own category of medical procedure, and a medical service can only fit into one of the subsections in (5)(a)(2)(a)-(f).
11. Finally, citing to St. Augustine Pools, Inc. v. James M. Barker, Inc., 687 So. 2d 957 (Fla. 5th DCA 1997) [22 Fla. L. Weekly D432a], Plaintiff contends that Allstate’s “use of the phrase ‘subject to’ does not mean that the language is incorporated anything additional into the policy [sic].” (Pl. Mot., p. 2.). However, in Virtual Imaging, the Supreme Court held that insurers are only “required to give notice to its insured by electing the permissive Medicare fee schedules in its policy.” 2013 WL 3332385, *4. This simply involves giving notice of the election to apply fee schedules as the method of calculating reimbursements, and does not require incorporating anything into the policy. The Court finds the decision in St. Augustine is inapposite.
12. 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.
