24 Fla. L. Weekly Supp. 57a
Online Reference: FLWSUPP 2401GALIInsurance — Personal injury protection — Coverage — Emergency services — Deductible — Insurer improperly processed medical bills out of order by applying deductible to bill from emergency service provider, which was third bill received, instead of applying deductible to bills in order received
EMERGENCY MEDICAL ASSOCIATES OF TAMPA BAY, L.L.C., as assignee of Maximilian Galindo, Plaintiff, v. USAA GENERAL INDEMNITY COMPANY, Defendant. County Court, 7th Judicial Circuit in and for Volusia County. Case No. 2014 31127 COCI, Division 82. April 8, 2016. Angela A. Dempsey, Judge. Counsel: Robert D. Bartels, Bradford Cederberg, P.A., Orlando, for Plaintiff. Melanie Smith, Orlando, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTIONFOR SUMMARY JUDGMENT
THIS MATTER having come before this Honorable Court on February 29, 2016 on Plaintiff’s Amended Motion for Final Summary Judgment and Defendant’s Motion for Summary Judgment this Honorable Court having heard arguments of counsel and being otherwise fully advised in the premises, finds as follows:FACTS
1. On October 15, 2013, Maximilian Galindo (“Galindo”) was injured in an automobile accident and received emergency services and care from Plaintiff, Emergency Medical Associates of Tampa Bay, LLC (“EMATB”).
2. Plaintiff is an emergency room physician group licensed under Chapters 458 or 459 and provided emergency services and care, as defined by Florida Statute § 395.002(9), to Maximilian Galindo on October 15, 2013.
3. At the time of the accident, Galindo was insured under a policy of insurance with Defendant, USAA General indemnity Company (“USAA”) and carried personal injury protection (“PIP”) coverage of $10,000 with a $500 deductible.
4. EMATB obtained an assignment of benefits from Galindo when EMATB rendered the emergency services and care to Galindo on October 15, 2013.
5. The first medical bill that USAA received for payment under Galindo’s PIP coverage was from St. Joseph’s hospital in the amount of $535.04. This bill was received by USAA on October 25, 2013.
6. The second medical bill that USAA received for payment under Galindo’s PIP coverage was from Trans Care Medical Transport (Ambulance) in the amount of $557.60. This bill was received on November 1, 2013 at 1:52 p.m.
7. The third medical bill that USAA received for payment under Galindo’s PIP coverage was from Plaintiff in the amount of $217. This bill was received on November 1, 2013 at 5:20 p.m.
8. There is no dispute that: a) St. Joseph’s Hospital (first bill received) and Trans Care Medical Transport (second bill received) do not qualify as providers under Fla. Stat. § 627.736(4)(c), b) EMATB’s bill was received within thirty (30) days of USAA receiving notice of the loss, c) EMATB qualifies as a provider under Fla. Stat. § 627.736(4)(c).
9. For reasons unclear to this Court, USAA did not apply Galindo’s $500 PIP deductible to either the first or second bill received in this matter. Inexplicably, instead, USAA applied the $500 to the third bill received from EMATB, which entirely consumed EMATB’s bill. USAA then applied the remainder of the deductible to the first bill received and then issued payment to the hospital. USAA did not reduce the second bill at all, allowed it in full, did not apply the deductible the second bill at all, and paid it at 80%.
10. Based upon the record evidence before the Court and for the reasons set forth below, the Court finds that USAA improperly processed medical bills out of order by applying the $500 PIP deductible to the third bill received from EMATB instead of the first bill received from St. Joseph’s hospital and that USAA improperly processed EMATB’s bill by applying the $500 PIP deductible to EMATB’s bill in derogation of Fla. Stat. § 627.736(4)(c).
CONCLUSIONS OF LAW
The legal issue presented here is whether USAA improperly processed medical bills by applying the PIP deductible to bills out of order, in derogation of Fla. Stat. §627.736(4) and Fla. Stat. §627.739(2).APPLYING THE PIP DEDUCTIBLE OUT OF ORDER
With regard to USAA’s decision to apply Galindo’s PIP deductible to the third bill received instead of applying the PIP deductible to the first bill received, it is USAA’s position that even though EMATB’s bill was the third bill received, it should get moved to the “front of the line” as the first “compensable” bill received. However, there is no suggestion by USAA that the bills from St. Joseph’s Hospital and Trans Care Medical Transport (first and second bills received) were not compensable. To the contrary, those two bills were paid by USAA (USAA reduced the hospital bill 75% of the usual and customary charge, applied the remainder of the deductible to the hospital bill and then paid the remainder of the bill and USAA allowed the ambulance bill in full). It is EMATB’s position that bills are to be paid, under the PIP statute, as the loss accrues (in order of receipt) and that bills that are not protected under Fla. Stat. §627.736(4)(c) must be applied to any applicable PIP deductible pursuant to Fla. Stat. §627.739.
The Court finds no merit to USAA’s argument and finds the bills were improperly processed out of order by USAA for the following reasons: 1) Fla. Stat. §627.736(4)(c) clearly states that “Upon receiving notice of an accident that is potentially covered by personal injury protection benefits, the insurer must reserve $5,000 of personal injury protection benefits for payment to physicians licensed under chapter 458 or chapter 459 or dentists licensed under chapter 466 who provide emergency services and care, as defined in s. 395.002, or who provide hospital inpatient care. The amount required to be held in reserve may be used only to pay claims from such physicians or dentists until 30 days after the date the insurer receives notice of the accident. After the 30-day period, any amount of the reserve for which the insurer has not received notice of such claims may be used by the insurer to pay other claims.” (emphasis added).
Fla. Stat. §627.739(2) clearly states that “[t]he deductible amount must be applied to 100 percent of the expenses and losses described in s. 627.736” (emphasis added).
There is no dispute that the first bill received by USAA in this case was the bill from St. Joseph’s Hospital in the amount of $535.04 and the second bill from Trans Care in the amount of $557.60. Regardless of the manner in which USAA calculated/applied the deductible, the $500.00 PIP deductible would have been satisfied prior to reaching Plaintiff’s bill. Even under Defendant’s own argument that bills received must be applied to the deductible pursuant to Fla. Stat. §627.739(2), the deductible should have been applied to the first bill received from St. Joseph’s Hospital. 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’ notice of loss to the carrier (i.e. EMATB in this case). The other $5,000.00 in PIP benefits is available immediately for processing of medical bills from other providers. The Court agrees with EMATB and finds, in this case, that USAA could have, and should have, processed the first bill received from St. Joseph’s hospital and the second bill from Trans Care (if need be) by applying the contractual PIP deductible of $500.00 to that/those bill/bills and then paying the remainder, pursuant to the policy, under Galindo’s PIP coverage. Had the bills been properly processed, in this manner, the deductible would have been exhausted, the deductible would not have been improperly applied to the third bill received (EMATB’s bill) and EMATB would have been paid the PIP benefits sued upon in this matter.1
WHEREFORE, the Court grants Plaintiff’s Motion for Final Summary Judgment and orders that Plaintiff is entitled to payment of $173.60 (which is 80% of Plaintiff’s $217 charge) plus statutory interest of $19.29 (which was calculated at 4.75% from the date Defendant received Plaintiff’s bill on November 1, 2013) for a total sum due of $192.89 for which let execution issue forthwith. The Court finds Plaintiff is hereby entitled to reasonable attorney’s fees and costs and reserves jurisdiction to determine the amount.
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1The Court notes that had USAA received EMATB’s bill first, then the application of the deductible to their bill would have been proper in light of the recent opinion in Mercury Ins. Co. of Florida v. Emergency Physicians of Central, etc., 182 So.3d 661 (5th DCA 2015) [40 Fla. L. Weekly D2364a].
