24 Fla. L. Weekly Supp. 766a
Online Reference: FLWSUPP 2409DUMEInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy that provides that insurer will pay no more than 80% of 200% of allowable amount under Medicare Part B fee schedule clearly and unambiguously elects to limit reimbursement to permissive statutory fee schedule — Deductible — Proper formula for payment of PIP claim requires that statutory reductions be applied to charges before deductible is subtracted from resulting amount
ADVANCED CHIROPRACTIC AND MEDICAL CENTER, CORP., a/a/o Nethanel Dumesle, Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 13-12197 (52). August 19, 2016. Giuseppina Miranda, Judge. Counsel: Gary Marks and Kathy Eikosidekas, Marks & Fleischer, for Plaintiff. Brian S. Goldstein and Patrick J. Gerace, Progreessive PIP House Counsel, Fort Lauderdale, for Defendant.
REVERSED. FLWSUPP 2711DUME
FINAL SUMMARY JUDGMENTIN FAVOR OF DEFENDANT
THIS CAUSE having come before the Court on for hearing on June 6, 2016 on the Defendant’s Motion for Summary Judgment dated October 26, 2015, and the Court having reviewed the Motion, the entire Court file, and the relevant legal authorities; having heard argument; having made a thorough review of the matters filed of record; and having been sufficiently advised in the premises, the Court finds as follows:
A. That the fee schedule has been properly incorporated into the policy by a clear and unambiguous election of the fee schedule to limit reimbursement. This election is delineated in the “Personal Injury Protection Coverage Endorsement” section of the policy titled “Unreasonable or Unnecessary Medical Benefits”.
The policy specifically notifies the insured that:
“We will determine to be unreasonable any charges incurred that “exceed the maximum charges set forth in Section 627.736(5)(a)(1)(a through f ) of the Florida motor Vehicle No-Fault Law. . . we will limit reimbursement to, and pay no more than, 80 percent of the following schedule of maximum charges:
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. . .”
B. Plaintiff asserts that Defendant has improperly utilized the fee schedule for services which were applied to the $1,000.00 deductible under the policy.
C. The pertinent part of the policy which applies to the deductible reads, in part, as follows:
“When a deductible applies, the deductible will be applied to 100% of the expenses and losses covered. . .”
D. This Court disagrees with the Plaintiff’s analysis that the initial dates of service which fall under the deductible should be applied “as charged” by the provider.
E. This Court, instead, agrees with Defendant that there is a requirement that a reasonableness analysis be applied to ALL charges, including those which fall within the insured’s deductible. See Bethesda Memorial Hospital a/a/a Markeith Donally v. Geico General Insurance Company, Case No. 14-4553 COCE (53) (Judge Robert Lee 17th Cir.) [22 Fla. L. Weekly Supp. 1097a]; Garrison Prop. & Cas. Ins. Co. v. New Smyrna Imaging, LLC, Case No. 13-03-AP (18th Cir. App. 2015) [23 Fla. L. Weekly Supp. 708a], and Progressive American Ins. Co. v. Munroe Regional Health System Inc. d/b/a Munroe Regional Medical Center, Case No. 14-11-AP (18th Cir. App. 2015) [23 Fla. L. Weekly Supp. 707a].
F. This Court finds fee schedule must be applied to all charges, including those applied to the deductible.
Based on the foregoing, is hereby ORDERED AND ADJUDGED Defendant’s Motion for Summary Judgment is GRANTED.
IT IS THEREFORE ORDERED AND ADJUDGED that Plaintiff, Coral Springs Physicians Associates, Inc., shall take nothing by this action. FINAL JUDGMENT is hereby entered in favor of the Defendant, Progressive American Insurance Company, and it shall go hence forth without day. The Court reserves jurisdiction determine entitlement to reasonable fees and costs.
