23 Fla. L. Weekly Supp. 265a
Online Reference: FLWSUPP 2303SIKEInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy does not provide clear and unambiguous notice of intent to limit reimbursement to permissive statutory fee schedule
HEALTH DIAGNOSTICS OF ORLANDO, LLC, d/b/a STAND UP MRI OF ORLANDO, a/a/oLORETTA SIKES, Plaintiff, vs. 21ST CENTURY CENTENNIAL INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 2014-CC-3758-O. April 28, 2015. Tina L. Caraballo, Judge. Counsel: Hans Kennon, Morgan & Morgan, P.A., Orlando, for Plaintiff. Erin D. Sparks, Law Office of Sanabria Llorente & Associates, Maitland, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FORSUMMARY JUDGMENT AND DENYINGDEFENDANT’S MOTION FOR SUMMARY JUDGMENT
THIS CAUSE having come before the Court for hearing on April 14, 2015, on the Plaintiff and Defendant’s Cross Motions for Summary Judgment and, having reviewed the motion, the policy of insurance, the pleadings, having heard argument, reviewed the relevant legal authorities, and been sufficiently advised in the premises, the Court finds as follows:
1. The sole legal issue for determination is whether 21st Century Centennial Insurance Company’s (“21st Century”) insurance policy allowed it to limit reimbursement of the bill for services at issue pursuant to the schedule of maximum charges described in §627.736(5)(a)2, Florida Statutes, or whether the policy requires it to pay 80% of all reasonable charges.1
2. The policy language fails to comply with the requirements set forth by the Florida Supreme Court in GEICO Gen. Ins. Co. v. Virtual Imaging Svcs., Inc., 141 So. 3d 147 (Fla. 2013) [38 Fla. L. Weekly S517a].
3. The policy language is unclear and ambiguous in how it would execute a limitation on benefits, and as such, renders ineffectual its attempt at notice of such limitation. “In order for an exclusion or limitation in a policy to be enforceable, the insurer must clearly and unambiguously draft a policy provision to achieve that result.” Id. at 157 (citing Auto-Owners Ins. Co. v. Anderson, 756 So. 2d. 29, 36 (Fla. 2000))
Accordingly, it is ORDERED
1. Plaintiff’s Motion for Summary Judgment is GRANTED.
2. Defendant’s Motion for Summary Judgment is DENIED.
3. Defendant must reimburse Health Diagnostics of Orlando, LLC d/b/a Stand Up MRI of Orlando a/a/o Loretta Sikes 80% of the amount Plaintiff billed for the services at issue less the amount paid to date because it failed to properly adopt the fee schedule limitations.
4. Plaintiff is entitled to attorney’s fees pursuant to § 627.428, Florida Statutes. The Court reserves ruling on the amount of attorney’s fees and costs.
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1The parties agreed that if the insurance policy did not make the proper election, 21st Century would owe the difference between 80% of the amount charged by the provider and the 80% of 200% of Medicare Part B that was actually paid.
