24 Fla. L. Weekly Supp. 969b
Online Reference: FLWSUPP 2411CLARInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy providing that insurer will pay 80% of reasonable expenses, but also providing that in no event will insurer pay more than 80% of No-Fault Act schedule of maximum charges, provides clear and unambiguous notice of intent to limit reimbursement to permissive statutory fee schedule
PAN AM DIAGNOSTIC SERVICES, INC., d/b/a WIDE OPEN MRI, a/a/o Hudland Clarke, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 14-000181 COSO (62). March 2, 2017. Terri-Ann Miller, Judge.
ORDER DEFENDANT’S AMENDEDMOTION FOR SUMMARY JUDGMENTAND ENTRY OF FINAL JUDGMENT
THIS CAUSE came before this Court upon Defendant’s Amended Motion for Summary Judgment.
State Farm Mutual Automobile Insurance Company (“State Farm”) asserts that the subject insurance policy, Form 9810A, permits State Farm to limit reimbursement for medical services based on the schedule of maximum reimbursements set forth in Fla. Stat. § 627.736, and that the policy provides proper notice to its insured of its election to use this fee schedule.
Pan Am Diagnostic Services, Inc. d/b/a Wide Open MRI (“Pan Am”) filed a Response and/or Cross-Motion to Defendant’s Amended Motion for Summary Judgment. Pan Am asserts that State Farm’s policy does not provide sufficient notice to the insured of State Farm’s election to use the fee schedules.
The court considered the competing motions, argument of counsel, case law and exhibits presented and makes the following findings:
1. According to the Complaint, on August 9, 2013, Hudland Clarke was injured in a motor vehicle accident.
2. As a result of the accident, Pan Am rendered medical services to Hudland Clarke on September 6, 2013.
3. Pan Am submitted a bill to State Farm on behalf of Hudland Clarke for treatment on September 6, 2013 in the total amount of $2,150.00.
4. State Farm issued a policy of insurance to Mr. Clarke that provided $10,000.00 in Personal Injury Protection benefits, subject to the terms and conditions of the policy and Florida law. The policy did not provide medical payments coverage.
5. State Farm paid $939.87 to Pan Am for services rendered to Mr. Clarke.
6. State Farm limited its payment based the schedule of maximum charges found in Fla. Stat. § 627.736.
7. The controlling policy form for this case is Form 9810A, which provides, in relevant part:
Insuring Agreement
Wewill pay in accordance with the No-Fault Act properly billed and documented reasonable charges for bodily injury to an insured, caused by an accident resulting from the ownership, maintenance, or use of a motor vehicle as follows:
1. Medical Expenses
We will pay 80% of properly billed and documented medical expenses, but only if that insuredreceives initial services and care from a provider described in A. below within 14 days after the motor vehicle accident that caused bodily injury to that insured.
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Limits
1. We will not pay any charge that the No-Fault Act does not require us to pay, or the amount of any charge that exceeds the amount the No-Fault Act allows to be charged.
2. The most we will pay for each injured insured as a result of any one accident is $10,000 for all combined Medical Expenses, Income Loss, and Replacement Services Loss, described in the Insuring Agreement of this policy’s No-Fault Coverage.
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We will limit payment of Medical Expenses described in the Insuring Agreement of this policy’s No-Fault Coverage to 80% of a properly billed and documented reasonable charge, but in no event will wepay more than 80% of the following No-Fault Act “schedule of maximum charges” including the use of Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services, including applicable modifiers:
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f. For all other medical services, supplies, and care, 200 percent of the allowable amount under:
(I) The participating physicians fee schedule of Medicare Part B, except as provided in sub-sub-subparagraphs (II) and (III).
(II) Medicare Part B, in the case of services, supplies, and care provided by ambulatory surgical centers and clinical laboratories. (III) The Durable Medical Equipment Prosthetics/Orthotics and Supplies fee schedule of Medicare Part B, in the case of durable medical equipment.
However, if such services, supplies, or care is not reimbursable under Medicare Part B, as provided in this sub-subparagraph, then we will limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation, as determined under s. 440.13, Florida Statutes, and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided. Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation (Florida Rules of Procedure for Worker’s Compensation Adjudication) will not be reimbursed by us.
For purposes of the above, the applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect on March 1 of the year in which the services, supplies, or care is rendered and for the area in which such services, supplies, or care is rendered, and the applicable fee schedule or payment limitation applies throughout the remainder of that year, notwithstanding any subsequent change made to the fee schedule or payment limitation, except that it will not be less than the allowable amount under the applicable schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.
8. State Farm’s Policy Form 9810A clearly and unambiguously provided proper notice to its insured that it may limit payment pursuant to the schedule of maximum charges in Fla. Stat. § 627.736.
9. Pan Am’s bill was paid at an appropriate and allowable amount pursuant to the terms, conditions, limitations, and exclusions of the subject policy of insurance under which the instant claim is made, as well as Fla. Stat. § 627.736.
10. No further amounts are due to Pan Am from State Farm because State Farm met its obligations under the policy of insurance and Florida law.
11. Final summary judgment is hereby GRANTED in favor of State Farm. Plaintiff’s Response and/or Cross-Motion to Defendant’s Amended Motion for Summary Judgment is hereby DENIED. Final Judgement is hereby entered in favor of Defendant.
