24 Fla. L. Weekly Supp. 991a

Online Reference: FLWSUPP 2411ROUSInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy that states that insurer will limit reimbursement to 80% of properly billed reasonable charge but in no event will pay more than 80% of schedule of maximum charges clearly and unambiguously elects to limit reimbursement to permissive statutory fee schedule

THOMAS ROUSH, M.D. and/or COLUMNA, INC. (a/a/o Brittney D. Edwards), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 14-04773 SP 25. November 7, 2016. Laura Anne Stuzin, Judge. Counsel: Eduardo E. Dieppa, Dieppa Law Firm, P.A., and Dewayne K. Terry, Rubenstein Law, P.A., for Plaintiff. Michael S. Walsh, Kubicki Draper, P.A., for Defendant.

ORDER GRANTING DEFENDANT’S AMENDEDMOTION FOR FINAL SUMMARY JUDGMENT

THIS CAUSE, having come before the Court on the motion of Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY (“State Farm”) for Motion for Final Summary Judgment and the Court, having heard argument on October 24, 2016, having reviewed the relevant filings and otherwise having been fully advised in the premises, the Court hereby finds as follows:

FACTS

1. The Plaintiff, Thomas Roush M.D. and/or Columna Inc. filed this lawsuit to recover Florida No-Fault (“PIP”) benefits allegedly due for medical services provided to the Claimant, Britney D. Edwards (the “claimant”), under an automobile insurance policy issued by State Farm and governed by the Florida No-Fault (“PIP”) Statute, section 627.736, Florida Statutes (2012) (“§ 627.736”). The State Farm policy at issue is Policy Form 9810.7 including Endorsements 6910.3 and 6126LS which were effective as of November 16, 2012 and which was in full force and effect at the time of the accident on March 9, 2013. The policy provided $10,000.00 in Personal Injury Protection (PIP) benefits.

2. On or about March 9, 2013, the Claimant allegedly sustained injuries in an automobile accident.

3. Pursuant to an assignment of benefits provided by the Claimant, the Plaintiff submitted bills to State Farm totaling $650.00 (the “Bills”) for medical services allegedly rendered to the Claimant for the date of service of April 25, 2013.

4. State Farm paid the Plaintiff $281.82 for the amounts billed by the Plaintiff in the Bills. The benefits were paid pursuant to the terms and conditions of the 9810.7 policy which included Endorsements 6910.3 and 6126LS. This amount equals eighty percent (80%) of the total allowable medical expenses calculated pursuant to the schedule of maximum charges set forth in §627.736(5)(a)1 (2012) (the “schedule of maximum charges”).

NATURE OF THE ISSUE

Whether State Farm’s 98107 policy including Endorsements 69103 and 6126LS clearly and unambiguously gave notice to the insured that the State Farm may limit payment to the schedule of maximum charges in Florida Statue 627.736 (5)(a)1.

THE 6126LS ENDORSEMENT

The 6126LS endorsement states in pertinent part :

This endorsement is part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement.

NO-FAULT — COVERAGE P

The following is added to No-Fault — Coverage P:

We will limit reimbursement of medical expenses to 80 percent of a properly billed reasonable charge, but in no event will we pay more than 80 percent of the following schedule of maximum charges:

a. For emergency transport and treatment by providers licensed under Chapter 401, Florida Statutes, 200 percent of Medicare.

b. For emergency services and care provided by a hospital licensed under Chapter 395, Florida Statutes, 75 percent of the hospital’s usual and customary charges.

c. For emergency services and care as defined by s. 395.002, Florida Statutes, provided in a facility licensed under Chapter 395, Florida Statutes, rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community.

d. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services.

e. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.

f. For all other medical services, supplies, and care, 200 percent of the allowable amount under the participating physicians fee schedule of Medicare Part B. However, if such services, supplies, or care is not reimbursable under Medicare Part B, 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 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 at the time the services, supplies, or care is rendered and for the area in which such services, supplies, or care is rendered, except that it will not be less than the allowable amount under the participating physicians schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.

ANALYSIS

The Court specifically finds the following:

1) Pursuant to Florida Statute §§ 627.736(a)(1) and (5)(a)1., State Farm is required to pay a reasonable amount for medically necessary services. Thus, the language of State Farm’s policy regarding a “reasonable charge” is simply consistent with the PIP statute itself. The PIP Statute provides that an insurer may limit payment of a reasonable charge by utilizing the schedule of maximum charges.

2) State Farm’s policy, including specifically the 6126LS endorsement, provided clear and unambiguous notice that State Farm may limit payment pursuant to the schedule of maximum charges outlined in Florida State §627.736(5)(a)1.

3) State Farm’s language as to payment of “80% of reasonable charges” and language in the 6910.3 endorsement pertaining to reasonable charge on page 4 does not create an ambiguity.

4) State Farm’s 9810.7 policy including the 6910.3 and 6126LS Endorsements comply with the notice requirements of Geico Ins. Co. v. Virtual Imaging Services, Inc., 141 So.3d 147 (Fla. 2013) [38 Fla. L. Weekly S517a] and the notice provision of Florida Statute §627.736(5)(a)(5).

5) Furthermore, Plaintiff made little to no argument at the hearing. Plaintiff provided nothing in opposition to Defendant’s Amended Motion for Summary Judgment. The Court finds that no genuine issue of material fact exists.

RULING

THEREFORE, it is ORDERED AND ADJUDGED

1) Defendant’s Amended Motion for Final Summary Judgment is hereby GRANTED.

2) That Final Summary Judgment is hereby entered in favor of Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, and against Plaintiff, THOMAS ROUSH, M.D. and/or COLUMNA, INC. (a/a/o BRITTNEY D. EDWARDS).

3) That the Plaintiff, THOMAS ROUSH, M.D. and/or COLUMNA, INC. (a/a/o BRITTNEY D. EDWARDS), take nothing by this action and that Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, shall go hence without day.

4) This Court reserves jurisdiction to entertain any motions regarding an award of attorneys’ fees and/or taxable costs in favor of the Defendant.