24 Fla. L. Weekly Supp. 850a
Online Reference: FLWSUPP 2410MORAInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Policy clearly and unambiguously permitted insurer to limit reimbursement by reference to schedule of maximum of charges
CEDA ORTHOPEDICS & INTERVENTIONAL MEDICINE OF SOUTH MIAMI, LLC a/a/o Juan Morales, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 15-008052 CC 23 (01). April 1, 2016. Myriam Lehr, Judge.
PARTIAL SUMMARY JUDGMENT FOR DEFENDANT,STATE FARM MUTUAL AUTOMOBILEINSURANCE COMPANY
This cause came to be considered on the Motion of the Defendant, State Farm Mutual Automobile Insurance Company (“State Farm”), for Partial Summary Judgment, and based upon the agreement of the parties, it is hereby ORDERED and ADJUDGED that:
1. The Motion is GRANTED. Partial Summary Judgment is hereby granted in favor of Defendant State Farm.
2. State Farm issued an automobile insurance policy (“the Policy”) that provided Florida no-fault benefits to Juan Morales, which was in full force and effect on the date of the alleged accident.
3. Juan Morales was allegedly involved in a motor vehicle accident on November 16, 2013, and the Plaintiff Cede Orthopedics & Interventional Medicine of South Miami, LLC, provided services to Juan Morales from November 27, 2013 through January 27, 2014, for injuries allegedly sustained in the accident, Plaintiff asserts standing to sue based upon an assignment of benefits from Juan Morales.
4. Plaintiff submitted bills to Defendant for services in connection with its treatment of Juan Morales.
5. In making partial payment, Defendant relied upon the language of the Policy, which provides:
(Policy Form 9810A at 16):
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 we pay 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:
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:
(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.
6. The Court finds that, consistent with this policy language, State Farm properly limited those reimbursements to Plaintiff based upon the application of the schedule of maximum charges set forth in section 627.736(5), Florida Statutes (2013).
7. The Court finds that the Policy is clear and unambiguous and permits State Farm to limit reimbursement by reference to the schedule of maximum charges as a matter of law.
8. Any reimbursements determined to be due shall be limited by the schedule of maximum charges.
