23 Fla. L. Weekly Supp. 247a
Online Reference: FLWSUPP 2303STEVInsurance — Personal injury protection — Coverage — Medical expenses — Emergency medical condition — Unless medical provider, as expressly defined by statute, makes affirmative determination that injured party had emergency medical condition, benefits are limited to $2500 — No merit to plaintiff’s argument that insurer was required to pay out full $10,000 in PIP benefits unless a medical provider expressly stated or determined that claimant did not have an emergency medical condition
RONALD C. STEVENSON, Plaintiff, v. UNITED SERVICES AUTOMOBILE ASSOCIATION, Defendant. County Court, 1st Judicial Circuit in and for Okaloosa County. Case No. 2014 CC 001093. December 8, 2014. Order on Motion for Rehearing April 28, 2015. Patricia S. Grinsted, Judge. Counsel: Woodburn S. Wesley, Jr., for Plaintiff. David Hwalek, for Defendant.
ORDER DENYING PLAINTIFF’S MOTIONFOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE came on to be heard on November 19, 2014, upon Plaintiff’s Motion for Partial Summary Judgment, e-filed with the Court on August 7, 2014. Plaintiff, Ronald C. Stevenson, appeared through counsel, Woodburn S. Wesley, Jr. Defendant, United Services Automobile Association (USAA), appeared through counsel, David Hwalek.
The Court, having heard the arguments of counsel and reviewed the case law submitted in support of each party’s position, respectfully denies Plaintiff’s Motion for Partial Summary Judgment.FINDINGS OF FACT
In reaching this conclusion, the court FINDS AS FOLLOWS:
a. Plaintiff, Ronald C. Stevenson, was injured in a motor vehicle accident which occurred on July 2, 2013. At the time of this accident, plaintiff had coverage under a policy of insurance with defendant, USAA, that provided him with up to $10,000 in No-Fault/Personal Injury Protection (PIP).
b. Following that accident, USAA was billed $49,766 for plaintiff’s care by three different medical providers: Ft. Walton Beach Medical Center (FWBMC), White Wilson Medical Center (WWMC), and Jacksonville ER.
c. Because no authorized physician, dentist, physician assistant, or advanced registered nurse practitioner determined that plaintiff, Ronald C. Stevenson, had an emergency medical condition, as required by § 627.736(1)(a)3 and 4, Fla. Stat.1, and by plaintiff’s policy of insurance (which mirrors the statutory language), USAA paid out only $2,500 in PIP benefits.
d. USAA declined to pay the additional $7,500 in benefits because plaintiff, despite numerous requests from USAA, failed to provide medical documentation showing a determination by a qualified medical care provider that plaintiff had suffered an emergency medical condition. It is not disputed that such purported documentation was provided to USAA for the first time on November 14, 2014.
CONCLUSIONS OF LAW
Plaintiff argues that because no provider of medical care expressly stated or determined that plaintiff, Ronald C. Stevenson, “did not have” an emergency medical condition, USAA must, by default, pay out the full $10,000 in PIP benefits. Plaintiff further argues that because the term “determine” [in the context of establishing whether plaintiff has an emergency medical condition] is ambiguous in that neither the statute nor the policy define that term. Plaintiff argues that under the circumstances where the medical records are silent on the issue and the policy has made no provision for that contingency, there has been no determination that plaintiff “does not have” an emergency medical condition and full benefits must be paid.
Plaintiff’s policy with USAA, which mirrors the statutory language, must be read in its entirety. The only reasonable and harmonious interpretation of the statute which makes sense is that full benefits are payable only in the event that a qualified medical provider has determined that the claimant had an emergency medical condition. Unless a medical provider, as expressly defined by statute, makes an affirmative determination that the injured party had an emergency medical condition, benefits are limited to $2,500.2
To interpret the statute otherwise ignores both the plain language of the statute and the legislative intent for the 2012 statutory revision to the Personal Injury Protection medical benefits under the No Fault Law, as set out in The Florida Senate House Message Summary and The Florida Senate 2012 Bill Summaries cited by USAA in support of its position. “The full $ 10,000 PIP medical benefit is only available if a physician, osteopathic physician, dentist, or a supervised physician’s assistant or advanced registered nurse practitioner determines that the insured has an ‘emergency medical condition.’ Otherwise, the PIP medical benefit is limited to $2,500.”3
It is, therefore, ADJUDGED that Plaintiff’s Motion for Partial Summary is DENIED.
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1The portion of § 627.736, Fla. Stat. (2013), relevant to this case states: “(1)(a) . . . .The medical benefits provide reimbursement only for:
3. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. up to $ 10,000 if a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464 has determined that the injured person had an emergency medical condition.
4. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. is limited to $2,500 if a provider listed in subparagraph 1. or subparagraph 2. determines that the injured person did not have an emergency medical condition.”
2Sendy Enivert v. Progressive Select Insurance Co., Case No.: 14-CV-80279-RYSKAMP/HOPKINS (U.S. Dist. Ct. Southern Dist. Of Florida, West Palm Beach Division, July 22, 2014, Judge Kenneth L. Ryskamp.) [25 Fla. L. Weekly Fed. D123a]; Glenaan Robbins v. Garrison Property and Casualty Insurance Co., Case No. 13-81259-Civ-Scola (U.S. Dist Ct. Southern Dist. of Florida, July 18, 2014, Judge Robert N. Scola) [25 Fla. L. Weekly Fed. D125a]; Southside Chiropractic Centre v. USAA General Indemnity, 22 Fla. L. Weekly Supp. 152a (Fla. 17th Jud. Cir., County Ct., June 10, 2014, Judge Pratt); Medical Center of Palm Beaches v. USAA Casualty Insurance Co., Case No. 50 2013 SC 012523 XXXX MB (Fla. 15th Jud. Cir., County Ct., August 20, 2014, Judge Bosso-Pardo).
3The Florida Senate House Message Summary, HB 119, dated March 9, 2012 re: Motor Vehicle Personal Injury Protection Insurance, prepared by The Profesional Staff of the Banking and Insurance Committee.
__________________ORDER ON PLAINTIFF’S MOTION FORRE-HEARING OR CLARIFICATION
THIS CAUSE came on to be heard on April 10, 2015, upon Plaintiff’s Motion for Re-hearing or Clarification, e-filed on December 22, 2014, seeking clarification or rehearing of the Order Denying Plaintiff’s Motion for Partial Summary Judgment, entered December 8, 2014. Plaintiff, Ronald S. Stevenson, appeared through counsel, Woodburn S. Wesley, Jr. Defendant, United Services Automobile Association (USAA), appeared through counsel, David Hwalek.
The Court, having heard and considered the additional arguments of counsel and having reviewed the case law submitted in support of each party’s position, finds that the holding and reasoning cited by this Court in the Order Denying Plaintiff’s Motion for Partial Summary Judgment, entered December 8, 2014, is supported by the weight of authority and shall stand as written.
For purposes of clarification, the patient/insured seeking the full $10,000 in PIP benefits has an affirmative obligation to provide the insurer with medical documentation showing an express determination by a “qualified medical care provider,” as defined by statute,1 that plaintiff had suffered an emergency medical condition.
Plaintiff’s suggestion that the insurance adjuster deduce that conclusion from a review of the insured’s medical records does meet the statutory requirements. The insurance adjuster cannot make a determination of “emergency medical condition” because the adjuster does not meet the statutory definition of “qualified medical care provider.” The insurer cannot employ a physician or nurse (as defined by statute) to make that determination because the insurer is not a “provider” of the medical services.
It is, therefore ADJUDGED that Plaintiff’s Motion for Clarification is GRANTED, as expressed herein, but Plaintiff’s Motion for Re-Hearing is respectfully DENIED.
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1§ 627.736(1)(a)3 and 4, Fla. Stat. (2013).
