22 Fla. L. Weekly Supp. 341a
Online Reference: FLWSUPP 2203ARODNOT FINAL VERSION OF OPINION
Subsequent Changes at 22 Fla. L. Weekly Supp. 686aInsurance — Personal injury protection — Coverage — Emergency services — Deductible — No error in finding that, where both emergency service providers and other medical providers seek PIP benefits, deductible must be applied to benefits paid to other providers rather than those paid to emergency service providers
USAA GENERAL INDEMNITY COMPANY, Appellant, vs. EMERGENCY PHYSICIANS OF CENTRAL FLORIDA, LLP, a/a/o Adriel Rodriguez, Appellee. Circuit Court, 18th Judicial Circuit (Appellate) in and for Seminole County. Case No. 13-17-AP. L.T. Case No. 12-SC-0705-19P-S. October 16, 2014. Appeal from the County Court for Seminole County. Honorable Jerri L. Collins, County Court Judge. Counsel: Douglas H. Stein and Stephanie Martinez, for Appellant. Dean A. Mitchell, for Appellee.
(RECKSIEDLER, Judge.) The Appellant seeks review of the trial court’s entry of summary judgment in favor of the Appellee. This case addressed the interplay and interpretation of Fla. Stat. §627.736(4)(c), providing for a prioritization of certain PIP benefits, and Fla. Stat. §627.739(2), addressing the application of a deductible in PIP cases. The trial court found that the deductible must be applied to benefits paid to non-priority providers when both priority and non-priority providers seek payment of PIP benefits. For the reasons stated below, that is a reasonable interpretation of the statutes, and summary judgment was properly granted in favor of the Appellee.
In this case, the policyholder was involved in an accident. The Appellant first received a bill from the Appellee for $446 and later received a bill from a chiropractic provider in the amount of $2,860. Since the policyholder’s insurance policy included a $500 deductible, the Appellant first applied the deductible to the Appellee’s bill, meaning that the Appellee was not reimbursed from the policy at all, and the remaining $54 was applied to reduce the chiropractor’s reimbursement. The trial court found that the system was created to ensure that medical providers were fully reimbursed, and therefore the entire $500 deductible should have been applied against the chiropractor’s claim. Therefore, summary judgment was granted in favor of the Appellee and the Appellant’s competing motion for summary judgment was denied.
“Issues of statutory interpretation are reviewed under a de novo standard.” Kephart v. Hadi, 932 So. 2d 1086, 1089 (Fla. 2006) [30 Fla. L. Weekly S182a]. The parties dispute whether the trial court properly relied upon tenets of statutory construction in construing the statutes.
Fla. Stat. §637.736(4)(c) was written to ensure that certain medical providers, including physicians, dentists, and emergency providers (“priority providers”), receive full payment for their services after an automobile accident. To accomplish this objective, the Legislature mandated that $5,000 of the $10,000 PIP benefits be set aside for payment only to those priority providers. Now, for 30 days following an automobile accident, only those priority providers’ bills may be paid from that pool, while bills from other providers, such as chiropractors, massage therapists, or acupuncturists (“non-priority providers”), are paid from the other pool, up to a maximum of the remaining $5,000. Unlike the non-priority providers, the priority providers are not initially subjected to a $5,000 cap, as they may receive reimbursement up to the policy limits within that 30 day period. However, if after 30 days the priority providers have not claimed the entire $5,000 that had been set aside, the non-priority providers may be reimbursed from the previously reserved funds.1
This case involved the application of the deductible to these policy claims. The trial court correctly understood that the Legislature created this two-tiered system to ensure that certain medical providers are fully reimbursed. There is no language in the statutes that exempts the priority claimants from any deductible that may be due and owing, nor is there any statutory language that specifically requires the insurance company to apply the deductible in any manner.
This puts the priority providers in a catch-22 when submitting their claims. On one hand, in order to obtain full reimbursement, they must submit their claims within 30 days. However, doing so means that the deductible will be applied against their bills. If they wait to submit their bills to avoid having the deductible applied to them, they run a risk that they will not be fully reimbursed.2 In cases without substantial priority medical bills, savvy non-priority providers will wait to submit their bills on the 31st day after an accident to ensure that the deductible will not be applied against their claims. This contravenes the intent of this statutory scheme.
Since there is no language dictating the method by which an insurance company should apply the deductible, the trial court was entitled to enforce the legislative intent of the statutory scheme. Accordingly, summary judgment was properly granted in favor of the Appellee.
AFFIRMED.
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1In other words, if a policyholder accrues $3,000 in medical bills and $7,000 in non-priority bills, the doctors are paid $3,000 and the non-priority providers are paid $5,000 within 30 days after the accident. On the 31st day after the accident, the remaining $2,000 of set aside benefits would be made available to the non-priority providers. In another scenario, if the policyholder accrues $5,000 in medical and $7,000 non-priority bills, the medical providers are guaranteed $5,000, so long as the claims are submitted within 30 days of the accident, and the non-priority providers are not fully reimbursed. In this situation, it does not matter whether the non-priority providers’ claims were submitted first.
2The trial court recognized that an insured may incur bills only from priority providers. In such a case, the court recognized that the deductible would be properly applied against the priority medical providers’ claims.
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