24 Fla. L. Weekly Supp. 131a
Online Reference: FLWSUPP 2402IMPERInsurance — Personal injury protection — Coverage — Medical expenses — Lawfully rendered services — Medical clinic that is wholly owned by licensed massage therapist does not qualify for exemptions from licensure delineated in PIP statute and, therefore, was required to obtain health care clinic license as condition precedent to receiving reimbursement of PIP benefits — Services provided to insureds by unlicensed clinic are unlawful and noncompensable
IMPERIAL FIRE & CASUALTY INSURANCE COMPANY, Plaintiff, vs. FINLAY DIAGNOSTIC CENTER, Defendant. Circuit Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 2014-6307-CA 01 (08). May 12, 2016. Honorable Gisela Cardonne Ely, Judge. Counsel: Michael A. Rosenberg, Roig Lawyers, Deerfield Beach, for Plaintiff. Maria E. Corredor, Corredor Husseini & Snedaker, PA., Miami, for Defendant.
FINAL SUMMARY JUDGMENTIN PLAINTIFF’S FAVOR
THIS CAUSE, having come before the Court on January 26, 2016, on Plaintiff’s Motion for Final Summary Judgment and after hearing argument from counsel, it is further ORDERED AND ADJUDGED as follows:
I. Facts
The Plaintiff, IMPERIAL, is a corporation licensed in the State of Florida that is engaged in the business of automobile insurance and conducts business in Miami-Dade County, Florida.
The Defendant, FINLAY DIAGNOSTIC CENTER, is a Florida Corporation that operates as a medical clinic with its principal place of business at 8756 SW 8th Street, Miami, FL 33174, which offers health care services to individuals and which tenders charges for reimbursement for such services.
The Plaintiff, IMPERIAL, issued a policy of automobile insurance to HECTOR MAURY which inured to the benefit of Patient A and Patient B (hereinafter referred to as “Insureds”) under which the Defendant, FINLAY, sought payment.
At all times material, the Defendant, FINLAY, was operating as a medical health care clinic, was tendering charges to an insurer and allegedly rendered medical treatment to the Insureds, who were purportedly injured in an automobile accident.
The Defendant, FINLAY, applied to the Agency for Health Care Administration (or “AHCA”) for a Certificate of Exemption from Licensure as a Health Care Clinic on October 27, 2010. The basis for Defendant’s, FINLAY, requesting a Certificate of Exemption was that Eddian Rodriguez, a massage therapist, was the 100% owner of the clinic, supervised business activities and was responsible for federal and state regulation. The application was executed by Eddian Rodriguez, a licensed massage therapist.
The Agency for Health Care Administration, issued a Certificate of Exemption to the Defendant, FINLAY, on November 23, 2010, confirming that FINLAY had affirmed its exempt status under Ch. 489, Florida Statutes, and that the clinic was allegedly wholly owned within the meaning of the, Paragraph 400.9905(4)(g), for licensed massage therapist.
Chapter 2012-197, Laws of Florida (a/k/a HB 119), repealed the AHCA exemptions for Massage Therapists and other practitioners, so that those practitioners could no longer bill for PIP goods and services unless the entity met a new and separate exemption in the PIP statutes. The Defendant, FINLAY, is wholly owned by a licensed massage therapist, which is not a listed exemption under The Florida Motor Vehicle No-Fault Act (the “PIP Statute”).
The Defendant, FINLAY, accepted an Assignments of Benefits from the Insured(s), allegedly entitling it to received payment for alleged medical services directly from the Plaintiff, IMPERIAL.
Subsequently, the Defendant, FINLAY, submitted charges for payment of PIP benefits to the Plaintiff, IMPERIAL.
II. The PIP Law
Under the PIP Statute, individuals who are injured in an automobile accident may seek reimbursement for medically necessary expenses (Personal Injury Protection or “PIP” claims”), up to a maximum of $10,000 in benefits. Insurers are only required to pay 80% of all reasonable medical expenses for medically necessary services.
At all times material, the PIP Statute requires services to be lawfully rendered in order to be compensable. See §627.736(5)(a)(1), Florida Statutes.
“Lawful” or “lawfully”, as defined in §627.732(11), Florida Statutes, means to be “in substantial compliance with all relevant applicable criminal, civil, and administrative requires of state and federal law related to the provision of medical services or treatment.”
Clinics must comply with the HCCA in order to “lawfully” provide services within the meaning of §627.732(11), Florida Statutes.
At all times material, the PIP Statute does not require an insurer or insured to pay a claim or charges for any service that was not lawful at the time it was rendered. See §627.736(5)(b)(1)(b), Florida Statutes.
Thus, services that are performed by a healthcare provider that is not appropriately licensed are not “lawfully” provided as required by Florida’s PIP statute.
III. The Health Care Clinic Act (“HCCA”)
Part X, Chapter 400, Florida Statutes, (2013), the “Health Care Clinic Act” outlines the licensing requirements for health care clinics to operate in the State of Florida.
Subsection 400.9905(4), “Definitions”, defines “clinic”, and therefore which entities are required to be licensed under this Chapter, as “an entity where health care services are provided to individuals and which tenders charges for reimbursement for such services, including a mobile clinic and a portable equipment provider.”
Subsection 400.9905(4), “Definitions”, goes on provide various exemptions to the definition and licensing requirement of a “clinic”. See 400.9905(4)(a)-(n) for each possible exemption.
In particular, subsection 400.995(4)(g) provides an exemption for a clinic wholly owned by licensed health care practitioner, which states in pertinent part:
(4) ‘Clinic’ means an entity where health care services are provided to individuals and which tenders charges for reimbursement for such services, including a mobile clinic and a portable equipment provider. As used in this part, the term does not include and the licensure requirements for this part do not apply to. . .
(g) A sole proprietorship, group practice, partnership, or corporation that provides health care services by licensed health care practitioners under . . . chapter 480 [Massage Therapy] . . . and that is wholly owned by one or more licensed health care practitioners, or the licensed health care practitioners set forth in this paragraph and the spouse, parent, child or sibling of a licensed health care practitioner if one of the owners who is a licensed health care practitioner is supervising business activities and is legally responsible for the entity’s compliance with all federal and state laws. However, a health care practitioner may now supervise services beyond the scope of the practitioner’s license, except that, for the purposes of this part, a clinic owned by a licensee in s.456.052(3)(b) which provides only services authorized pursuant to s. 456.053(3)(b) may be supervised by a licensee specified in s. 456.053(3)(b). [Emphasis and redactions supplied for ease of reading]
In 2012, however, the Legislature required mandatory licensing for all clinics holding an exempt status, whether by issuance of Certificate of Exemption or self-determined, in order for clinic to receive reimbursement pursuant to the “PIP Statute”. See, HB 119: Chapter 2003-197, laws of Florida.
Section 400.9905 states, following subsection 400.9905(4)(n): “Notwithstanding this subsection, an entity shall be deemed a clinic and must be licensed under this part in order to receive reimbursement under the Florida Motor Vehicle No-Fault Law, ss. 627.730-627.7405, unless exempted under s. 627.736(5)(h)” (emphasis added).
Hence, a clinic must be licensed under Part X, Chapter 400 to receive reimbursement for PIP benefits, unless it qualifies for an exception listed in Section 627.736(5)(h), which states:
As provided in s. 400.9905, an entity excluded from the definition of a clinic shall be deemed a clinic and must be licensed under part X of chapter 400 in order to receive reimbursement under ss.627.730-627.405. However, this licensing requirement does not apply to:
(1) An entity wholly owned by a physician licensed under chapter 458 or chapter 459, or by the physician and the spouse, parent, child or sibling of the physician;
(2) An entity wholly owned by a dentist licensed under chapter 466, or by the dentist and the spouse, parent, child, or sibling of the dentist;
(3) An entity wholly owned by a chiropractic physician licensed under 460, or by the chiropractic physician and the spouse, parent, child or sibling of the chiropractic physician;
(4) A hospital or ambulatory surgical center licensed under chapter 395;
(5) An entity that wholly owns or is wholly owned, directly or indirectly by a hospital or hospitals licensed under chapter 395; or
(6) An entity that is a clinical facility affiliated with an accredited medical school at which training is provided for medical students, residents or fellows. (Emphasis added)
Accordingly, although a clinic may have an exempt status from licensure under subsection 400.9905(4)(g), for services other than PIP services, it must be licensed under the Health Care Clinic Act in order to receive reimbursement under the PIP statute, unless it qualifies for one of the six exceptions delineated in §627.736(5)(h)(1)-(6) above.
Further, subsection 400.9905(3) provides that “All charges or reimbursement claims made by or on behalf of a clinic that is required to be licensed under this part, but that is not so licensed . . . are unlawful charges, and therefore are noncompensable and unenforceable.”
IV. THE POLICY
Defendant alleges that the Plaintiff’s policy is vague as it relates to reimbursement for medical services to clinics that are not licensed. Defendant’s strained reading on the policy would render only unlawful charges compensable. This Court finds that Defendant’s arguments are unfounded and that policy at issue is clear. See generally Garcia v. Fed. Ins. Co., 969 So. 2d 288, 291 (Fla. 2007) [32 Fla. L. Weekly S657a] (citing Taurus Holdings, Inc. v. U.S. Fid. & Guar. Co., 913 So. 2d 528, 532 (Fla. 2005) [30 Fla. L. Weekly S633a] (finding that a provision is not ambiguous simply because it is complex or requires analysis. . . .[i]f a policy provision is clear and unambiguous, it should be enforced according to its terms.)
FINLAY argues the policy provides for payment under the circumstances because the policy specifically states IMPERIAL will pay, or alternatively, the policy is ambiguous and must be construed against IMPERIAL. The insurance policy states:
However, “we will not pay:
b. Any charge or reimbursement made by or on behalf of a clinic that is required to be licensed as a clinic as provided in Fla.Stat. §400.9905, unless that entity is:
(1) An entity wholly owned by a physician licensed under chapter 458 or chapter 459, or by the physician and the spouse, parent, child, or sibling of the physician;
(2) An entity wholly owned by a dentist licensed under chapter 466, or by the dentist and the spouse, parent, child, or sibling of the dentist;
(3) An entity wholly owned by a chiropractic physician licensed under chapter 460, or by the chiropractic physician and the spouse, parent, child, or sibling of the chiropractic physician;
(4) A hospital or ambulatory surgical center licensed under chapter 395;
(5) An entity that wholly owns or is wholly owned, directly or indirectly, by a hospital or hospitals licensed under chapter 395; or
(6) An entity that is a clinical facility affiliated with an accredited medical school at which training is provided for medical students, residents, or fellows.
(a) But is not so licensed; or
(b) That is otherwise operating in violation of the Florida Health Care Clinic Act.
Imperial Insurance Policy, Part E — Florida Motor Vehicle No-Fault Law, General Provisions Relating to Part E — Section J
The Court does not agree and interprets the “But is not so licensed” to apply to subparagraph 6 rather than the entire paragraph b.
V. CONCLUSION
The Defendant, FINLAY, being wholly owned by a license massage therapist, does not qualify for any of the exceptions delineated in §627.736(5)(h)(1)-(6).
Therefore, the Defendant, FINLAY, was required to obtain a Health Care Clinic license as a condition precedent to receiving reimbursement of PIP benefits.
As a result of Defendant’s, FINLAY, failure to obtain a Health Care Clinic License, this Court also finds that the charges submitted to Plaintiff, IMPERIAL, by Defendant, FINLAY, are unlawful and thus, noncompensable pursuant to Florida’s Motor Vehicle No-Fault Law.
Therefore, Plaintiff, IMPERIAL, is not legally obligated to pay the pending claim (claim number 00068925 for assignor’s Anthony Blackhood and Harold Blackhood). Summary Judgment is hereby entered in favor of the Plaintiff. As such, final judgment is entered in favor of the Plaintiff Fire & Casualty Insurance Company against the Defendant, Finlay Diagnostic Center. The Court reserves jurisdiction to tax attorney fees and costs upon proper motion.
