24 Fla. L. Weekly Supp. 61a

Online Reference: FLWSUPP 2401GRIFInsurance — Personal injury protection — Coverage — Emergency services — Deductible — Where insurer received bills from other medical providers prior to bill from plaintiff emergency service provider, insurer should have applied deductible to other providers’ bills, thereby extinguishing deductible before payment of plaintiff’s bill — No merit to argument that because insurer is mandated by statute to reserve $5,000 for emergency service providers deductible was properly applied to plaintiff’s bill as “first compensable bill” even though plaintiff’s bill was fourth bill received — Insurer cannot dispute reasonableness of charge or relatedness and medical necessity of services after it allowed full amount of charge when applying charge to deductible and conceded reasonableness, relatedness and necessity at deposition of its corporate representative — Standing — Assignment — Document assigning insured’s rights, benefits and causes of action to plaintiff provider conferred standing on plaintiff

EMERGENCY MEDICAL ASSOCIATES OF TAMPA BAY, L.L.C., as assignee of Christopher Griffith, Plaintiff, v. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 7th Judicial Circuit in and for Volusia County. Case No. 2015 20434 CONS. February 2, 2016. Shirley A. Green, Judge. Counsel: Rutledge M. Bradford, Bradford Cederberg, Orlando, for Plaintiff. John E. Eckard,

II, Roig Lawyers, Orlando, for Defendant.ORDER GRANTING PLAINTIFF’S MOTIONFOR FINAL SUMMARY JUDGMENT ANDDENYING DEFENDANT’S MOTION FOR FULLAND FINAL SUMMARY JUDGMENT

THIS MATTER having come before this Honorable Court on Plaintiff’s Motion for Final Summary Judgment and Defendant’s Motion for Full and Final Summary Judgment and this Honorable Court having heard arguments of counsel on December 30, 2015 and being otherwise fully advised in the premises, states as follows:

I. FACTS

This is a claim for Personal Injury Protection benefits (hereinafter “PIP”) arising out of a motor vehicle collision that occurred on or about November 14, 2014. The Plaintiff in this matter is EMERGENCY MEDICAL ASSOCIATES OF TAMPA BAY, L.L.C., as assignee of Christopher Griffith (hereinafter “Plaintiff”). At all times material to the subject cause of action, the assignor, Christopher Griffith, was covered under a policy of automobile insurance by the Defendant, USAA CASUALTY INSURANCE COMPANY (hereinafter “Defendant”) which provided Personal Injury Protection coverage (“PIP”) for injuries Christopher Griffith sustained in the above-referenced accident. The Plaintiff rendered emergency service and care to the assignor, Christopher Griffith, on November 15, 2014, in the Emergency Department of St. Joseph’s Hospital following the above referenced collision. On November 15, 2014, EMERGENCY MEDICAL ASSOCIATES OF TAMPA BAY, L.L.C. (“EMATB”) obtained an assignment of benefits from Christopher Griffith in consideration and in exchange for the emergency services and care provided by EMATB to Christopher Griffith on November 15, 2014.

The chronological order of Defendant’s receipt of the medical bills for the medical services rendered to Christopher Griffith as a result of the November 14, 2014 loss at issue is undisputed. The first medical bill that Defendant received for payment under Christopher Griffith’s PIP coverage for the subject automobile accident was from St. Joseph’s Hospital in the amount of $8,106.86 which was received by Defendant on November 28, 2014. Defendant reduced St. Joseph’s Hospital’s medical bill to a total allowed amount (“Reimbursement Amount”) of $6,080.15 and applied only $370.00 of the alleged deductible to St. Joseph’s Hospital’s bill. Defendant paid $4,568.12 in PIP benefits for St. Joseph’s Hospital’s bill. Defendant alleges that the policy of automobile insurance at issue included a PIP deductible in the amount of $1,000.00 and that the PIP deductible was applicable to the claim of Christopher Griffith. The Plaintiff disputes this and argues the policy of automobile insurance at issue did not include a PIP deductible and argues no PIP deductible should have been applied to the claim of Christopher Griffith surrounding the loss of November 14, 2014.

The second medical bill that Defendant received for payment under Christopher Griffith’s PIP coverage for the subject automobile accident was from Injury Centers of Central Tampa, Inc. in the amount of $524.99 which was received by Defendant on December 6, 2014. Defendant reduced Injury Centers of Central Tampa, Inc.’s bill to a total allowed amount (“Reimbursement Amount”) of $384.10 and applied no deductible to Injury Centers of Central Tampa Inc.’s bill.St. Joseph’s Hospital’s bill. Defendant paid $307.28 in PIP benefits for Injury Centers of Central Tampa, Inc.’s bill.

The third medical bill that Defendant received for payment under Christopher Griffith’s PIP coverage for the subject automobile accident was from Injury Centers of Central Tampa, Inc. in the amount of $1,643.87 which was received by Defendant on December 8, 2014. Defendant reduced said bill from Injury Centers of Central Tampa, Inc. to a total allowed amount (“Reimbursement Amount”) of $894.20 and applied no deductible to said bill from Injury Centers of Central Tampa Inc. Defendant paid $715.36 in PIP benefits for said bill from Injury Centers of Central Tampa, Inc.

The fourth medical bill that Defendant received for payment under Christopher Griffith’s PIP coverage for the subject automobile accident was from Plaintiff for the date of service at issue (November 15, 2014) in the amount of $630.00. Plaintiff’s bill was received by Defendant on December 9, 2014. Defendant allowed Plaintiff’s bill in full ($630.00) and applied $630.00 of the alleged PIP deductible to Plaintiff’s bill.

II. ISSUES TO BE DETERMINED BY THE COURT

The issues presented by the parties for determination by this Court on competing motions for final summary judgment are as follows: 1) whether Defendant improperly processed medical bills by applying an alleged PIP deductible to said medical bills out of order of receipt in derogation of Fla. Stat. §627.736 and Fla. Stat. §627.739; 2) whether relatedness and necessity of the services provided to Christopher Griffith by Plaintiff as well as reasonableness of Plaintiff’s charges are resolved; and 3) whether the assignment of benefits executed by Christopher Griffith on November 15, 2014 in favor of EMATB conferred standing upon EMATB to file the present lawsuit and maintain this action.

III. ANALYSIS AND RULING

A. Defendant Improperly Processed Medical Bills by Applying an Alleged PIP Deductible to Said Medical Bills Out of Order of Receipt in Derogation of Fla. Stat. §627.736 and Fla. Stat. §627.739

It is Defendant’s position and Defendant argues that even though Plaintiff’s bill was the fourth bill received by Defendant, Plaintiff’s bill must be moved to the “front of the line” as “the first compensable bill.” Defendant concedes that Plaintiff’s bill meets the protection afforded pursuant to Fla. Stat. § 627.736(4)(c) but Defendant argues that as a result of said protection, Plaintiff’s bill was applied to the deductible as “the first compensable bill.” Defendant argues that Defendant was permitted to apply the alleged deductible to Plaintiff’s bill out of order instead of applying the alleged deductible to the first bill received (St. Joseph’s Hospital’s bill) which would have extinguished any alleged deductible. It is Plaintiff’s position that Defendant should not have applied any alleged PIP deductible to Plaintiff’s bill and Defendant breached the contract at issue considering 1) Defendant’s violation of Fla. Stat. §627.736 which requires application of a PIP deductible to a loss (i.e., medical bill) as loss accrues (i.e., order of receipt), 2) Defendant’s violation of Fla. Stat. §627.739(2) which requires application of a PIP deductible to 100% of expenses, 3) there was no PIP deductible associated with the policy of insurance at issue, and 4) there was no PIP deductible applicable to the PIP coverage of Christopher Griffith surrounding the loss of November 14, 2014. The Court finds Defendant’s argument without merit and finds Plaintiff’s argument fundamentally sound and directly in line with the law.

The bill from St. Joseph’s Hospital was clearly determined by Defendant to be compensable as Defendant paid a total of $4,568.12 of St. Joseph’s Hospital’s bill. To further solidify this fact, in deposition the Defendant’s Corporate Representative testified that St. Joseph’s Hospital’s bill was reasonable, related to the loss at issue and medically necessary. Therefore, Defendant’s argument that Plaintiff’s bill was the “first compensable bill” is directly contrary to the actions taken by Defendant and the record evidence in this matter. Plaintiff’s bill was the fourth compensable bill received by Defendant. As a result, Plaintiff’s bill should not, and could not, be applied to any alleged deductible.

Fla. Stat. §627.736(4) reads in pertinent part that “[b]enefits due from an insurer . . . are due and payable as loss accrues upon receipt of reasonable proof of such loss and the amount of expenses and loss incurred which are covered by the policy issued . . .” Defendant in the present matter received reasonable proof of three covered losses and the amounts of expenses incurred for same prior to Defendant receiving Plaintiff’s bill. Further, Fla. Stat. §627.739(2) reads in pertinent part that “[t]he deductible amount must be applied to 100 percent of the expenses and losses described in s. 627.736.” Pursuant to Fla. Stat. §§627.736(4) and §627.739(2), Defendant was required to process the bill from St. Joseph’s Hospital prior to the Plaintiff’s bill. If Defendant had processed the St. Joseph’s Hospital bill properly, no alleged deductible would have been available under any circumstances for application to Plaintiff’s bill. However, Defendant did not process the medical bills in compliance with Fla. Stat. §§627.736(4) and §627.739(2), thereby breaching the contract at issue. As stated by Courts of this State, “those medical bills which were received first, are to be applied to the deductible when received.” Dr. Garrett R. Weinstein, D.C., P.A. a/a/o Devonte St. Louis v. United Auto. Ins. Co., 18 Fla. L. Weekly Supp. 480b (Fla. 17th Jud. Cir., Broward Co., March 11, 2011).

Under Fla. Stat. §627.736(4)(c), only $5,000.00 of the $10,000.00 in PIP benefits are to be reserved and held for payment to providers of emergency services and care who are licensed under chapter 458, 459 or 466 and who submit their bills within thirty (30) days of the carrier receiving notice of loss (EMATB qualifies for this reservation for payment mandate). However, the other $5,000.00 in PIP benefits is available immediately for processing of medical bills from non-protected providers (i.e., the St. Joseph’s Hospital bill in this matter). This Court finds that Defendant should have applied the alleged deductible to the first bill received (the unprotected St. Joseph’s Hospital bill) which would have without question extinguished any alleged PIP deductible.

Plaintiff also argues that there was no PIP deductible associated with the policy of insurance at issue as Defendant did not comply with the strict requirements of Fla. Stat. §627.739. Plaintiff argues that Defendant has failed to present this Court with any evidence as to the insurer’s offer of deductible options to its insured, premium reduction notice, or election of the deductible by the insured. Plaintiff argues that Defendant is required to present evidence of the PIP deductible election by the insured and the amount of same or no deductible can be deemed associated with the policy. In addition, it is Plaintiff’s position that in order for Defendant to limit coverage, meaning apply a PIP deductible, Defendant must affirmatively prove that its insured elected a PIP deductible and affirmatively prove the amount of same. In support of its position, Plaintiff points to the clear similarities between Fla. Stat. §627.727 (election of uninsured motorist coverage) and Fla. Stat. §627.739 (election of personal injury protection deductibles), for the proposition that it is the affirmative duty of the insurer to prove that it has complied with the law and obtained a PIP deductible election form. Interestingly, in the case at hand, the only deductible election form in the record is a blank, unchecked, unsigned election form attached as an exhibit to the deposition of Defendant’s Corporate Representative. The Court does not even have to determine whether a PIP deductible actually existed on the policy at issue or whether a PIP deductible was applicable to the claim of Christopher Griffith or Plaintiff’s bill because as discussed above, under no circumstances or argument presented could a PIP deductible be applied to Plaintiff’s bill at issue.

B. Relatedness and Necessity of the Services Provided to Christopher Griffith by Plaintiff as well as Reasonableness of Plaintiff’s Charges are Resolved

It is the Defendant’s position that although it allowed Plaintiff’s charges in full and applied the full amount of Plaintiff’s bill to the alleged deductible, it can nonetheless continue to challenge the causal relatedness and medical necessity of the services provided by the Plaintiff to Christopher Griffith and the reasonableness of Plaintiff’s charges for those services. It is Plaintiff’s position that Defendant’s actions in this claim dictate that these items are no longer at issue and are resolved. In support of its position, Plaintiff argues that Defendant 1) during the deposition of Defendant’s Corporate Representative it was confirmed that the services were related and necessary and that the Plaintiff’s charges were reasonable, and 2) clearly deemed the services to be causally related and medically necessary and Plaintiff’s charges to be reasonable as Defendant allowed Plaintiff’s bill in full (deeming the full amount of Plaintiff’s bill to be the “Reimbursement Amount” according to Defendant’s own Explanation of Reimbursement) and applied the entire amount of said bill to the alleged deductible. The Court finds Defendant’s argument without merit and finds Plaintiff’s argument fundamentally sound and directly in line with the law.

Defendant’s argument that Plaintiff’s burden has yet to be met in regards to the reasonableness of the Plaintiff’s charge as well as the relatedness and medical necessity of the services is in direct conflict with the record before this Court. First and foremost, Defendant’s Explanation of Reimbursement shows the charged amount of $630.00 for Plaintiff’s bill was allowed in full. Defendant’s Explanation of Reimbursement uses the term “Reimbursement Amount” to represent the allowed amount of $630.00, prior to application of the deductible and makes no mention of the Defendant challenging the reasonableness of the Plaintiff’s charge, causal relatedness or medical necessity of the services. According to General Star Indem. Co. v. West Florida Village Inn., Inc. “[t]he notion that a deductible could be applied to loss that is not covered by the policy is fundamentally unreasonable.” 874 So. 2d 26 (Fla. 2d DCA 2004) [29 Fla. L. Weekly D1070b]. PIP benefits are to cover reasonable, related and medically necessary services and when Defendant applied the deductible (albeit improperly) to Plaintiff’s bill it made the determination that the charged amount was reasonable and that the services were causally related and medically necessary. Additionally, during the deposition testimony of Defendant’s Corporate Representative it was conceded that the services were related and necessary in regard to the automobile accident of the patient/insured and the charge was reasonable. In fact, the Defendant’s Corporate Representative conceded that had Plaintiff’s bill not been applied to the deductible it would have been paid at 80 percent of the charged amount. If an insurer applies a deductible to a medical provider bill said services are “deemed medically necessary, and related to the accident.” Glenn V. Quintana, D.C., P.A. (a/a/o Melissa N. Evans) v. State Farm Mutual Automobile Insurance Company, 19 Fla. L. Weekly Supp. 882a (Fla. 11th Jud. Cir., Miami-Dade Co., July 11, 2012). Within its Motion for Full and Final Summary Judgment and in argument at the hearing, Defendant uses the phrase “compensable” to describe Plaintiff’s bill for the emergency services and care rendered to Christopher Griffith. As a result, Defendant via its own argument has conceded to the compensability of Plaintiff’s bill. “In order for a claim to be compensable, it must be reasonable, related, and medically necessary.” United Auto. Ins. Co. v. Riverside Medical Assoc., 20 Fla. L. Weekly Supp. 389a (Fla. 17th Jud. Cir., Appellate, December 13, 2012). When applied to a deductible and therefore found to be compensable, “bills cannot thereafter be ‘un-applied’ from said deductible.” Dr. Garrett R. Weinstein, D.C., P.A. a/a/o Devonte St. Louis v. United Auto. Ins. Co., 18 Fla. L. Weekly Supp. 480b (Fla. 17th Jud. Cir., Broward Co., March 11, 2011). Via Defendant’s actions and the record evidence before the Court, the services provided to Christopher Griffith by Plaintiff were related and necessary and the Plaintiff’s charge reasonable.

C. The Assignment of Benefits Executed by Christopher Griffith on November 15, 2014 In Favor of EMATB Conferred Standing Upon EMATB to File the Present Lawsuit and Maintain This Action

Defendant argues that the assignment of benefits at issue in this matter does not confer standing upon EMATB because EMATB is not the “Facility” (St. Joseph’s Hospital) and that EMATB is not mentioned specifically within the assignment. EMATB argues that EMATB (the emergency physicians who rendered emergency services and care to Christopher Griffith in the Emergency Room at St. Joseph’s Hospital) undisputably meets the definition of “Provider” within the assignment. Specifically, paragraph number three (3.) of the assignment defines “Provider” in part as the “emergency physicians” (i.e., EMATB). Paragraph seventeen (17.) (entitled “ASSIGNMENT OF BENEFITS”) of the document clearly assigns all Christopher Griffith’s “rights, benefits, privileges, protections, claims, causes of action, interests or recovery” under the policy at issue to EMATB, a defined “Provider.” Paragraph seventeen (17.) further states that “[t]his includes, without limitation, . . . personal injury protection.” The Court agrees that paragraph seventeen (17.) of the assignment at issue clearly distinguishes between “Facility” and “Provider” and that the document clearly assigns Christopher Griffith’s benefits under the policy to the “Facility” for the services provided by the “Facility” and to the “Provider” (EMATB) for services provided by EMATB.

A review of Florida law on the topic of assignments confirms that there are no express requirements that an assignment contain any particular words or terms. Assignments may be express or implied by the circumstances. Tunno v. Robert, 16 Fla. 738 (Fla. 1878); Mangum v. Susser, 764 So.2d 653 (Fla. 1st DCA 2000) [25 Fla. L. Weekly D1216a]. An assignment may be partly in writing, partly parol or it may be by a showing of circumstances in which the debtor is justified in making payment, regardless of whether there is anything in writing or in parol between the assignor and assignee. Protection House, Inc. v. Daverman and Associates, 167 So.2d 65 (Fla. 3rd DCA 1964). The law is clear that a valid equitable assignment exists where it is necessary to effectuate the plain intent of the parties or where to hold otherwise would be just. See Giles v. Sun Bank, NA, 450 So.2d 258 (Fla. 5th DCA 1984). No particular words or form of instrument is necessary to effect an equitable assignment, and any language, however informal, which shows an intention on one side to assign a right and an intention on the other side to receive it, if there is valuable consideration, will operate as an effective assignment. Id. See also, Boulevard Nat’l Bank of Miami v. Air Metal Indus., Inc., 176 So.2d 94 (Fla. 1865).

Additionally, Florida appellate case law provides excellent guidance on the lack of distinction between a direction to pay and an assignment. See generally, State Farm Fire and Cas. Co. v. Ray, 556 So.2d 811 (Fla. 5th DCA 1990); Schuster v. Blue Cross & Blue Shield of Florida, Inc., 843 So.2d 909 (Fla. 4th DCA 2003) [28 Fla. L. Weekly D505a]; Hartford Ins. Co. of Midwest v. O’Connor, 855 So.2d 189 (Fla. 5th DCA 2003) [28 Fla. L. Weekly D2140a]; Orion Ins. Co. v. Magnetic Imaging Systems I, 696 So.2d 475 (Fla. 3rd DCA 1997) [22 Fla. L. Weekly D1595c]; State Farm Mut. Auto. Ins. Co. v. Gonnella, 677 So.2d 1355 (Fla. 5th DCA 1996) [21 Fla. L. Weekly D1799d].

After careful review and consideration of the assignment of benefits upon which EMATB relies upon to assert standing in the instant matter, the Court agrees with EMATB’s position and finds that the document clearly assigns from Christopher Griffith, to EMATB (“Provider”), “all of my rights, benefits, privileges, protections, claims, causes of action, interests or recovery . . . arising out of any policy of insurance . . .” Such assigned rights, benefits, and causes of action include, but are not limited to, the right for EMATB to file suit to collect payment(s) due and owing under the subject policy of insurance. Accordingly, the assignment of benefits executed by Christopher Griffith in favor of EMATB conferred standing upon EMATB to pursue this action.

IV. CONCLUSION

The Court finds that no genuine issues of material fact remain. The Court finds that all issues have been disposed of by the Court, including but not limited to, any and all issues raised by the parties in the pleadings. Upon competing motions for final summary judgment, the Court finds that Plaintiff is entitled to Final Summary Judgment as a matter of law. Considering same, Plaintiff is entitled to PIP benefits in the amount of $504.00 (80 percent of $630.00).

IT IS HEREBY ORDERED AND ADJUDGED that:

Plaintiff’s Motion for Final Summary Judgment is hereby GRANTED.

Defendant’s Motion for Full and Final Summary Judgment is hereby DENIED.

Final Judgment is hereby GRANTED in favor of the Plaintiff, EMERGENCY MEDICAL ASSOCIATES OF TAMPA BAY, L.L.C., as assignee of Christopher Griffith, wherein Plaintiff shall recover from Defendant, USAA CASUALTY INSURANCE COMPANY, the sum of $504.00 plus 4.75% pre-judgment interest in the amount of $27.09 for a total sum of $531.09 for which sum let execution issue.* The Court finds Plaintiff is entitled to its reasonable attorneys’ fees and costs. The Court reserves jurisdiction to determine the amount of attorneys’ fees and costs to Plaintiff pursuant to Fla. Stat. §§627.736, 627.428 and 57.041.

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*Post-judgment interest of 4.75% per annum shall accrue on this judgment pursuant to Fla. Stat. § 55.03.