24 Fla. L. Weekly Supp. 964a
Online Reference: FLWSUPP 2411HERNInsurance — Personal injury protection — Coverage — Medical expenses — Insurer could limit reimbursement to schedule of maximum charges found in PIP statute where insurer advised insured that in no event will it pay more than 80% of schedule of maximum charges
LAKE WORTH CHIRO. ASSOC., INC., d/b/a CHIRO ASSOC. OF LAKE WORTH, a/a/o Ana Hernandez, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 50-2016-SC-006521 XXXX SB RS. March 6, 2017. Robert Panse, Judge. Counsel: Mac S. Phillips, Fort Lauderdale, for Plaintiff. Melissa McDavitt, West Palm Beach, for Defendant.
ORDER GRANTING DEFENDANT’S AMENDEDMOTION FOR PARTIAL SUMMARY JUDGMENTAND DENYING PLAINTIFF’S MOTIONFOR PARTIAL SUMMARYJUDGMENT
THIS CAUSE having come before the Court on February 28, 2017 upon Defendant Amended Motion for Partial Summary Judgment and Plaintiff’s Motion for Partial Summary Judgment on the issue of whether State Farm could limit reimbursement to the schedule of maximum charges found at Fla. Stat. § 627.736(5)(a)1, the Court having reviewed the motions, heard argument of counsel and after being otherwise fully advised in the premises, it is hereby
ORDERED and ADJUDGED, as follows:
1. Defendant’s Amended Motion for Partial Summary Judgement is GRANTED.
2. Plaintiff’s Motion for Partial Summary Judgment is DENIED.
In 2012, the Florida Legislature amended the PIP statute to include express directives as to how a carrier can adopt the Schedule of Maximum Charges (the “Schedule”). This case is governed by this newer provision, Fla. Stat § 627.736(5)(a)(5) which provides:
Effective July 1, 2012, an insurer may limit payment as authorized by this paragraph only if the insurance policy includes a notice at the time of issuance or renewal that the insurer may limit payment pursuant to the schedule of charges specified in this paragraph. A policy form approved by the office satisfies this requirement. . . .
State Farm has complied with the statutory requirements and advised the insured, that, in no event will it pay more than 80% of the “schedule of maximum charges”.
“[T]he PIP statute sets forth a basic coverage mandate: every PIP insurer is required to — that is, the insurer ‘shall’ — reimburse eighty percent of reasonable expenses for medically necessary services.” Geico General Insurance Co. v. Virtual Imaging Services, Inc., 141 So. 3d 147 (Fla. 2013) [38 Fla. L. Weekly S517a]. This provision is the heart of the PIP statute’s coverage requirements. Virtual Imaging, 141 So. 3d 155. Plaintiff’s position is that State Farm’s policy is ambiguous, arguing that the policy refers to both the “reasonableness” method of calculation and the Schedule. However, an insurer is simply not at liberty to remove the “reasonableness” coverage mandate from its policy. The State Farm policy clearly states it will be using the Schedule which allows the insurer to further limit reimbursement/payment. This plainly satisfies the notice requirement.
This Court further relies upon the recent Supreme Court decision Allstate Ins. Co. v. Orthopedic Specialists, __So. 3d__, 2017 WL 372092 (Fla. Jan. 26, 2017) [42 Fla. L. Weekly S38a]. The Supreme Court has clarified that an “election” of the Schedule is an election of a“payment limitation”option. See Orthopedic Specialists, 2017 WL 372092 at *1. There, the Court found that an election of the Schedule of Maximum Charges concerns only the election of a limitation on payment — as opposed to the election of an overall or exclusive payment methodology applicable to all PIP medical payments. The Schedule is simply an electable “cap” on payments.
Additionally, the Supreme Court clarified that the Section 5(a) schedules (including the “various federal and state medical fee schedules applicable to automobile and other insurance coverages”) “do not operate as ‘limitations’ on charges.” Id. Rather, they are “various relevant factors” that may be considered in determining the reasonableness of a charge for medical services. Id. State Farm’s definition of “reasonable charge” appropriately lists these factors as “various relevant factors” that may be considered in determining the reasonableness of charges.
Accordingly, State Farm may limit reasonable reimbursements based on the Schedule as a matter of law.
It is therefore ORDERED AND ADJUDGED that Defendant’s Amended Motion for Partial Summary Judgment is GRANTED.
