24 Fla. L. Weekly Supp. 1000a
Online Reference: FLWSUPP 2411CELEInsurance — Personal injury protection — Coverage — Medical expenses — Deductible — Insurer correctly applied statutory fee schedule to amount billed by medical provider before applying reduced amount to deductible
A FIRST CHOICE HEALTHCARE SYSTEMS, INC., (a/a/o Roger Celestin), Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 16-04714CONO (71). February 15, 2017. Louis H. Schiff, Judge. Counsel: Thomas Wenzel, The Law Firm of Cindy Goldstein, Coral Springs, for Plaintiff. Geoff Hirshberg, and Kevin Sincerbox, Progressive PIP House Counsel, Fort Lauderdale, for Defendant.
ORDER GRANTING PARTIAL SUMMARYJUDGMENT FOR DEFENDANT ON PROPERAPPLICATION OF THE DEDUCTIBLEUNDER THE STATUTES
THIS CAUSE having come before the Court for hearing on December 21, 2016 on Defendant’s Motion for Partial Summary Judgment, and based on the motions, pleadings, record evidence, and argument of counsel, the Court finds as follows:
The Plaintiff brought this declaratory action against the Defendant over PIP benefits as assignee of the insured, Roger Celestin. The two central issues in the instant case are: 1) whether the No-Fault statutory scheme permits the Defendant to reduce bills according to the “schedule of maximum charges” prior to applying said bills to a deductible and 2) whether Defendant is permitted to engage in the aforementioned practice pursuant to the subject policy of insurance. The Court finds that the first issue, a pure question of law, was ripe for summary judgment at the time of the hearing. However, due to an issue concerning outstanding discovery, the Court finds that the second issue was not ripe for summary judgment at the time of the hearing.
The policy at issue in this case provided $10,000.00 in PIP benefits and allegedly included a $1,000.00 deductible1. The issue in the case was whether the Defendant properly calculated the amount due to the Plaintiff from the insured for the portion of the charges which fell within the insurance policy deductible. This Court finds that the Defendant properly applied the deductible in this case.
Plaintiff billed $9,400.00 to Defendant. The Defendant adjusted the charges and determined that $6,826.66 was covered and compensable under the subject policy of insurance pursuant to the schedule of maximum charges as described in § 627.736(5)(a)(1-5), Fla. Stat. (2013), and applied the deductible to that amount. Plaintiff contends that the deductible should have been applied to the entire billed amount submitted by Plaintiff, prior to any fee schedule reductions. This Court finds that the Defendant properly applied the deductible pursuant to §627.739, Fla. Stat. (2008) and § 627.736, Fla. Stat. (2013)2. Section 627.739, Fla. Stat. requires a cross-reference to § 627.736, which places the insured in the shoes of the insurance carrier for charges that fall within the deductible elected in the policy of insurance.3 This Court adopts the Defendant’s position that the deductible is a basic part of the insurance policy4, which requires a reasonableness analysis pursuant to the policy.5 Defendant appropriately applied the covered charges to the policy deductible.6 Plaintiff contends that benefits are not the same as medical expenses, citing U.S. Sec. Ins. Co. v. Silva, 693 So.2d 593 (Fla. 3d DCA 1997) [22 Fla. L. Weekly D507a]. This court disagrees with Plaintiff’s interpretation of that case, which was regarding cut-off of P.I.P benefits based on an Independent Medical Examination, and instead finds persuasive additional language in that case that it is important for insurers to have “the opportunity to determine the legitimacy of a claim so that an appropriate decision may be made as to whether benefits should be paid.” Id at 596. This supports the Defendant’s position that a reasonableness analysis must occur prior to the application of the deductible and that the deductible only applies to covered expenses. This Court finds that the language of §627.736, 5(a)(4) prohibits a medical provider from balance billing an insured patient in excess of the fee schedule reductions, and therefore the insured patient would only be responsible for $1,000, and no more. This court also finds that Plaintiff’s affidavit of Dr. Goldstein as to the reasonableness of Plaintiff’s charges to be irrelevant to this legal issue.
IT IS THEREFORE ORDERED AND ADJUDGED that Partial Summary Judgment is granted in favor of the Defendant on the issue of whether the No-Fault statutory scheme permits Defendant’s application of the deductible methodology.
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1Due to the aforementioned issues discussed on the record concerning outstanding discovery, the Court declines to make any findings regarding the insurance policy.
2This Court finds that the relevant version of §627.739 is the 2008 version, not the 2003 version as contended by the Plaintiff, due to the PIP Sunset in 2007. Additionally, this Court finds that the relevant version to cross reference is §627.736, Fla. Stat. (2013) as there is clear Legislative intent as to what constitutes covered benefits under this version of the statute, i.e., “medical benefits do not include massage. . . .”
3See Mercury Ins. Co. of Florida v. Emergency Physicians of Cent., 182 So.3d 661 (Fla. 5th DCA 2015) [40 Fla. L. Weekly D2364a].
4See Digital Medical Diagnostics a/a/o Jesus Gaber, Miriam Gaber, and Lidice Soto v. United Auto. Ins. Co., 958 So.2d 505 (Fla. 3rd DCA 2007) [32 Fla. L. Weekly D1392a].
5See Progressive American Insurance Company v. Munroe Regional Health System, Inc., 14-11-AP (18th Judicial Circuit Appellate 2015) [23 Fla. L. Weekly Supp. 707a]; See also, Advanced Chiropractic and Medical Center, Corp., a/a/o Nethanel Dumesle v. Progressive American Insurance Company, COCE 13-12197 (52) (Fla. Brwd. Cty. 2016) [24 Fla. L. Weekly Supp. 766a]; See also, Florida Health Professionals Group a/a/o Sifontes, Idreinis, v. Progressive American Insurance Company, COCE-15-002261 (55) (Fla. Brwd Cty. 2016) [24 Fla. L. Weekly Supp. 732a]
6See General Star Indem. Co. v. West Florida Village Inn, Inc., 874 So.2d 26 (Fla. 2nd DCA 2004) [29 Fla. L. Weekly D1070b]
