22 Fla. L. Weekly Supp. 448a
Online Reference: FLWSUPP 2204WEINInsurance — 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
PEMBROKE PINES MRI, INC. d/b/a DPI OF PEMBROKE PINES a/a/o STEVEN WEINKLE, Plaintiff, v. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 14-000542 (55). October 17, 2014. Daniel J. Kanner, Judge. Scott W. Dutton, Dutton Law Group, Miami, for Defendant.
ORDER GRANTING SUMMARY JUDGMENT ANDFINAL JUDGMENT FOR DEFENDANT
This matter came on to be heard on October 6, 2014 on the Defendant, United Services Automobile Association Casualty Insurance Company’s (“USAA”) Motion for Summary Judgment, and after hearing argument of counsel, the Court grants the Defendant’s motion based on the following findings of fact and conclusions of law.
I. FINDINGS OF FACTS
1. Plaintiff filed the instant action for payment of PIP benefits on behalf of the alleged assignor, Steven Weinkle, which pertains to a policy of insurance issued by USAA and an automobile accident that occurred on March 13, 2013.
2. At the time of the accident on March 13, 2013, the assignor/claimant Steven Weinkle sought PIP benefits under a policy of insurance issued by the Defendant that provided personal injury protection (PIP) benefits for covered persons under the policy.
3. On May 9, 2013 the plaintiff performed two MRIs billed under CPT code 72148, and CPT code 72141.
4. When the Health Insurance Claims Forms for the charges in dispute were received by USAA, USAA responded to each set of charges with an Explanation of Reimbursement that stated: “Per F.S.A. 627.736(A)4, $2500 has been reimbursed. In order to make any additional reimbursement decisions, please provide the determination of the patient’s emergency medical condition by their provider authorized in 627.736(1)(a)3&4.”
5. Prior to the filing of the instant suit, no qualified medical provider authorized in section 627.736(1)(a)(3) submitted to USAA a written determination that the patient had an emergency medical condition.
6. Plaintiff sent a purported pre-suit demand letter dated October 3, 2013.
7. USAA responded with a letter dated November 6, 2013 stating, again, that the $2500 reimbursement limits had been reached and in order to make additional reimbursement decisions documentation was needed regarding the determination of an emergency medical condition by an authorized medical provider.
8. After Plaintiff filed this litigation and after Defendant filed its motion for summary judgment and Affidavit in support, on October 1, 2014 Plaintiff served the affidavit of Dr. José Marquez, M.D. . In his affidavit, Dr. Marquez opines that while he has not examined the claimant, he reviewed the patient’s medical records from which he has determined that the Claimant patient has an “emergency medical condition.”
9. According to the record, this is the first written notice ever provided to USAA that the patient in fact had an emergency medical condition. Under § 627.736(4)(b) USAA then had 30 days from the receipt of the written notice of the fact of a covered loss (EMC determination) before the Plaintiff’s charges would become overdue.
10. The key point argued at the October 6, 2014 motion for summary judgment hearing was “when does up to $10,000 in personal injury protection policy limits become available?” The Plaintiff contends that the reimbursement of personal injury protection medical benefits automatically defaults to $10,000 unless a treating provider opines that the patient did not have an emergency medical condition. The Defendant, in turn argues that up to $10,000 only becomes available when it has been determined that the injured person had an emergency medical condition by a qualified provider and the Defendant receives written notice of that determination.
11. During the course of the argument the Defendant pointed out that a total of six courts, four county courts and two federal courts, have now agreed that policy limits up to $10,000 only becomes available when a qualified provider has determined that the patient had an emergency medical condition.1 Notably, no court, county or federal, has agreed with the position taken by the Plaintiff on the issue.
II. CONCLUSIONS OF LAW
The issues involved in the subject lawsuit depend on the construction of the 2013 version of Florida Motor Vehicle No-Fault Law and the Defendant’s Policy which incorporates its terms as follows:
The medical benefits provide reimbursement only for:
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(3) Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. up to $10,000 if 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 has determined that the injured person had an emergency medical condition.
(4) Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. is limited to $2,500 if a provider listed in subparagraph 1. or subparagraph 2. determines that the injured person did not have an emergency medical condition.
An emergency medical condition is defined as “a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in . . . (a) serious jeopardy to patient health, (b) serious impairment to bodily functions, [or] (c) serious dysfunction of any bodily organ or part. See § 627.732(16), Fla. Stat. (2013) and Policy.
Courts have long held that a “statute should be interpreted to give effect to every clause in it, and to accord meaning and harmony to all of its parts.” Jones v. ETS of New Orleans, Inc., 793 So. 2d 912, 914-15 (Fla. 2001) [26 Fla. L. Weekly S549a]. When read together, the reimbursement clauses of the statute have a clear meaning — reimbursement of the insured’s medical benefits is limited to $2500 in the absence of a determination that the patient had an emergency medical condition as determined by a qualified provider. In the opinion of this court, no other reading of the statute makes sense.
As argued by the Defendant, six courts have now agreed with Defendant’s position that EMC benefits are only available where a determination of an EMC has been provided to the insurer by a statutorily authorized medical provider. Enivert v. Progressive Select Ins. Co., Case No. 14-CV-80279 (S.D. Fla. July 23, 2014) [25 Fla. L. Weekly Fed. D123a] (Order granting defendant’s motion to dismiss); Robbins v. Garrison Prop. & Cas. Ins. Co., Case No. 13-81259 (S.D. Fla. July 18, 2014) [25 Fla. L. Weekly Fed. D125a] (Order granting defendant’s motion to dismiss); Southside Chiropractic Centre, Inc., v. USAA Gen. Ind. Co., Case No.: COCE 13-020731 (Fla. Broward Cty. Ct. June 10, 2014) [22 Fla. L. Weekly Supp. 152a]; Orthopedic Specialists LLP v. USAA Cas. Ins. Co., Case No.: 502013 SC 13901 (Fla. Palm Beach Cty. Ct. June 3, 2014); Precision Diag., Inc. v. United Serv. Auto. Assoc., Case No. CONO 14-001263(72) (Fla. Broward Cty. Ct. Aug. 14, 2014) [22 Fla. L. Weekly Supp. 389c] (Final Judgment determining that $2500 cap applied absent a determination of an emergency medical condition) (Levy, J.); Medical Center of the Palm Beaches v. USAA Casualty Ins. Co., Case No. 50 2013 SC 012523 (Fla. Palm. Beach Cty. Ct. Aug. 20, 2014) [22 Fla. L. Weekly Supp. 279a] (granting USAA summary judgment on the $2500 limitation and certifying as a question of great public importance whether a certification by a statutorily authorized person is necessary to make benefits above $2500.00 available).
According to United States District Judge Robert N. Scola in Robbins v. Garrison Property & Cas. Ins. Co. “The statute does not contain a default provision establishing the coverage limit when a qualified medical professional ‘makes no determination that the patient did not have an emergency medical condition.’ ” . . . “For example, chiropractors are not listed among the medical professionals who may determine that an injured person had an emergency medical condition. Fla. Stat. § 627.736(1)(a)(3). But, chiropractors are included in the list of medical professionals who may determine that an injured person did not have an emergency medical condition. Fla. Stat. § 627.736(1)(a)(4). Under the Robbins interpretation, if the chiropractor remains silent, the injured person would be able to avoid the lower $2500 limit on PIP medical benefits.”
This rationale is similar to the Order Granting Defendant’s Motion To Dismiss With Prejudice from United States District Judge Kenneth L. Ryskamp in Enivert v. Progressive Select Ins. Co. where the court stated that “Enivert argues that, because a medical provider never determined that she did not have an EMC, she is entitled to full benefits. However, she ignores the language of Subsection (1)(a)(3). When interpreting a statute, the court must “construe the language within the context of the entire statutory scheme.” The PIP statute, read in its entirety, clearly indicates that a medical provider’s determination is required in order to receive reimbursement under either subsection of the statute. A medical provider did not determine that Enivert had an EMC, and she contends that she did not have one. Therefore, Enivert is not entitled to the full $10,000 and benefits and her claim fails.” (citations omitted).
Courts have long held that statutes must be read to give effect to each and every clause and to provide harmony and meaning to all their parts. Jones v. ETS of New Orleans, Inc., 793 So. 2d 912, 914-15 (Fla. 2001) [26 Fla. L. Weekly S549a]. Thus, “statutory phrases are not to be read in isolation, but rather within the context of the entire section.” Id. at 915. “It is axiomatic that all parts of a statute must be read together in order to achieve a consistent whole. Where possible, courts must give full effect to all statutory provisions and construe related statutory provisions in harmony with one another.” Forsythe v. Longboat Key Beach Erosion Control Dist., 604 So. 2d 452, 455 (Fla. 1992). It is a cardinal rule of statutory interpretation that courts should avoid readings that would render part of a statute meaningless. Id. at 456. The provisions of § 627.736, Fla. Stat. (2013), specifically subsections (1)(a)(3) and (1)(a)(4), have a clear and definite meaning when read together in harmony with one another, giving effect to all provisions, avoiding a reading that would render any part meaningless and avoiding an interpretation that would lead to an absurd result.2 That is, a qualified provider must determine that the patient had an emergency medical condition in order for up to $10,000 to be available for reimbursement of medical benefits. In turn, in the opinion of this Court, no provider who is a non-qualified physician would ever author a report to state that its patient did not have an emergency medical condition thereby limiting reimbursement of its own medical charges to $2500 instead of $10,000. To adopt such an argument would lead to the type of statutory interpretation that would lead to an absurd result that is to be avoided according to the courts.
In sum, § 627.736(1)(a)(3) and (1)(a)(4), Fla. Stat. address the amount of the services available to a claimant. To that end, subsection (1)(a)(3) provides for benefits of up to $10,000.00 if an authorized physician, dentist, PA, or ARNP has determined the claimant had an emergency medical condition. If such benefits were authorized regardless of the determination, subsection (1)(a)(3) would be meaningless, as would subsection (1)(a)(4), which follows. By including the conditions under which additional benefits may be authorized before the provision regarding the limitation of benefits, the legislature indicated by the terms it selected that § 627.736, Fla. Stat. (2013) would provide limited benefits based on the severity of the injury. No other interpretation can read the provisions in harmony to give effect and meaning to all.
It is therefore,
ORDERED AND ADJUDGED that the Defendant USAA Casualty Insurance Company’s Motion for Final Summary Judgment against the Plaintiff, Pembroke Pines MRI, Inc. doing business as DPI of Pembroke Pines be and hereby is, GRANTED. There was no additional reimbursement above the $2500 limit due or owing to the Plaintiff when it filed suit. It is further
ORDERED AND ADJUDGED that the Plaintiff, Pembroke Pines MRI, Inc. doing business as DPI of Pembroke Pines take nothing by this action and that Defendant USAA Casualty Insurance Company shall go hence without day. The Court reserves jurisdiction to determine the entitlement to and the amount of attorney’s fees and costs.
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1Enivert v. Progressive Select Ins. Co., Case No. 14-CV-80279 (S.D. Fla. July 23, 2014) [25 Fla. L. Weekly Fed. D123a] (Order granting defendant’s motion to dismiss); Robbins v. Garrison Prop. & Cas. Ins. Co., Case No. 13-81259 (S.D. Fla. July 18, 2014) [25 Fla. L. Weekly Fed. D125a] (Order granting defendant’s motion to dismiss); Southside Chiropractic Centre, Inc., v. USAA Gen. Ind. Co., Case No.: COCE 13-020731 (Fla. Broward Cty. Ct. June 10, 2014) [22 Fla. L. Weekly Supp. 152a]; Orthopedic Specialists LLP v. USAA Cas. Ins. Co., Case No.: 502013 SC 13901 (Fla. Palm Beach Cty. Ct. June 3, 2014); Precision Diag., Inc. v. United Serv. Auto. Assoc., Case No. CONO 14-001263(72) (Fla. Broward Cty. Ct. Aug. 14, 2014) [22 Fla. L. Weekly Supp. 389c] (Final Judgment determining that $2500 cap applied absent a determination of an emergency medical condition) (Levy, J.); Medical Center of the Palm Beaches v. USAA Casualty Ins. Co., Case No. 50 2013 SC 012523 (Fla. Palm. Beach Cty. Ct. Aug. 20, 2014) [22 Fla. L. Weekly Supp. 279a] (granting USAA summary judgment on the $2500 limitation and certifying as a question of great public importance whether a certification by a statutorily authorized person is necessary to make benefits above $2500.00 available).
2Courts must adhere to the reasonable and obvious meaning of a statute’s plain language over a meaning that would lead to an absurd result. See Tampa-Hillsborough County Expressway Auth., 444 So. 2d 926 (reversing the interpretation a district court gave to a statute regarding compensation to business owners in the event of an exercise of eminent domain, finding that the interpretation would easily lead to absurd and unfair results). As the Supreme Court stated in Tampa-Hillsborough County Expressway Auth., 444 So. 2d 926, “an interpretation of the language of a statute that leads to absurd consequences should not be adopted when, considered as a whole, the statute is fairly subject to another construction that will aid in accomplishing the manifest intent and the purposes designed.” Tampa-Hillsborough County Expressway Auth., 444 So. 2d at 929. Here, the interpretation of limited benefits advocated by the Defendant is the reasonable and workable result suggested by the plain language of the statute, read as a whole. Thus, this Court must determine that the Plaintiff, as assignee of the claimant, is entitled to reimbursement of up to $2,500.00, absent a reported emergency medical condition determination by a qualified physician, dentist, PA, or ARNP.
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