23 Fla. L. Weekly Supp. 602a
Online Reference: FLWSUPP 2306APPLInsurance — Personal injury protection — Coverage — Declaratory actions — Complaint seeking declaration that insurer must reimburse medical provider at rate of 200% of Medicare Part B fee schedule in effect at time service was rendered, including 2.2% update to fee schedule provided by Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, or at 2007 rate, if greater, states cause of action for declaratory relief — Motion to dismiss or for more definite statement is denied
APPLE MEDICAL CENTER, LLC, a Florida Corp. (a/a/o Brown, Michael 7), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 2015 3862 CC 23 (04). October 26, 2015. Jason Emilios Dimitris, Judge. Counsel: Robert B. Goldman, Florida Advocates, Dania Beach, for Plaintiff. Belayne D. Guerrero, for Defendant.
ORDER DENYING DEFENDANT’SMOTION TO DISMISS PLAINTIFF’S COMPLAINTFOR DECLARATORY RELIEF, OR IN THEALTERNATIVE, FOR MORE DEFINITE STATEMENT
THIS CAUSE came before the Court on October 23, 2015, upon Defendant’s Motion to Dismiss Plaintiff’s Complaint for Declaratory Relief, or in the Alternative, for More Definite Statement. This Court has considered the Complaint for Declaratory Relief, the Motion to Dismiss, or in the Alternative, for More Definite Statement, and Plaintiff’s Responses to the Motion and has considered the argument of counsel and the authorities presented in support of the positions of the respective parties.
For purposes of Defendant’s Motion to Dismiss, this Court must accept as true the following allegations of the Complaint:
Defendant State Farm Mutual Automobile Insurance Company (“State Farm”) issued personal injury protection insurance coverage insuring or otherwise covering the Claimant, Michael Brown. On or about April 22, 2010, Mr. Brown was involved in a motor vehicle accident, as a result of which he sought treatment with the Plaintiff Apple Medical Center, LLC (“Apple Medical”) on June 24, 2010. Mr. Brown equitably assigned to Apple Medical, and executed a written assignment of benefits, assigning to Apple Medical certain benefits payable pursuant to the policy of insurance issued by State Farm. Apple Medical timely submitted to State Farm claims for medical services rendered to Mr. Brown. State Farm issued payment to Apple Medical at 200% of the allowable amount under the Medicare Part B Physician Fee Schedule that was in effect from January 1, 2010 through May 31, 2010.
The Complaint further alleges that the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 provided for a 2.2 percent update to the 2010 Medicare Part B Physician Fee Schedule; that the Centers for Medicare and Medicaid Services increased the reimbursement rates for services rendered on or after June 1, 2010 through November 30, 2010; that based upon Section 627.736(5)(a)(2)(f), Florida Statutes, State Farm is precluded from reimbursing less than the statutory floor for reimbursements under the PIP schedule; and that State Farm should have issued payment at 200% of the allowable amount under the Medicare Part B Physician Fee Schedule in effect at the time the services were rendered.
The Complaint further alleges that Apple Medical is in doubt as to its rights under the contract of insurance and Section 627.736(5)(a)(2)(f), Florida Statutes, and seeks to have this court declare that State Farm must reimburse at the rate of 200% of the allowable amount under the Medicare Part B Physician Fee Schedule in effect at the time that the services were rendered, or at the 2007 rate if greater; that there is a bona fide, actual, present, and practical need for this declaration by the Court; that the declaration deals with a present, ascertained or ascertainable state of facts or present controversy as to a state of facts; that the parties have a present and actual controversy regarding the amount of coverage provided for this claim under the terms of the insurance contract and Section 627.736, Florida Statutes, and requires the Court’s resolution by this declaratory action; that Apple Medical has an actual, present, adverse and antagonistic interest in the declaration of how much coverage is available (as Apple Medical maintains that more insurance coverage is available to pay for its services) and this interest is directly antagonistic to State Farm who has an interest in declaring that less coverage is afforded and paid; that the antagonistic and adverse interests are all before the Court by proper process as Apple Medical has an assignment of insurance benefits and is the party seeking payment from State Farm.
The Court concludes that Apple Medical’s Complaint states a cause of action for Declaratory Relief and is sufficient as plead. Accordingly, it is
ORDERED AND ADJUDGED that Defendant’s Motion to Dismiss, or in the Alternative, for More Definite Statement is DENIED.
