24 Fla. L. Weekly Supp. 825a
Online Reference: FLWSUPP 2410WOLFInsurance — Personal injury protection — Coverage — Medical expenses — Deductible — Amount to be applied to PIP policy deductible is 100% of reasonable expenses, not 100% of amount billed by medical provider
MUSA CHIROPRACTICE AND WELLNESS CENTER, INC., as assignee for Melissa Wolfersberger, Plaintiff, vs. ESURANCE PROPERTY AND CASUALTY INSURANCE COMPANY, Defendant. County Court, 4th Judicial Circuit in and for Clay County. Case No. 2016-SC-615 C. August 17, 2016. Timothy R. Collins, Judge. Counsel: Adam Saben and Melissa Winter, for Plaintiff. Eric S. Shubow and Brendan N. Keeley, for Defendant.
[Note: Appeal Pending.]
ORDER ON THE PLAINTIFF’S MOTION FORSUMMARY JUDGMENT AND THEDEFENDANT’S MOTION TO DISMISS
THIS cause came to be heard on the Defendant’s Motion to Dismiss and the Plaintiff’s Motion for Summary Judgment and the Court, having considered the file and the argument of counsel, finds as follows:
A. The issue in this case is how to calculate the appropriate Personal Injury Protection medical benefit deductible pursuant to Section 627.736(2), Florida Statues.
B. The Plaintiff argues that the deductible is met when one hundred percent (100%) of the medical provider’s bill(s) total the deductible amount set forth in the policy. The Defendant argues that the deductible is met when one hundred percent (100%) of the “reasonable expenses” total the deductible amount set forth in the policy. See: §627.736(1)(a), Florida Statutes
C. In 2002 Section 627.739(2) provided, in pertinent part:
Insurers shall offer to each applicant and to each policy holder, upon renewal of an existing policy, deductibles, in the amounts of $250, $500, $1,000, and $2,000, such an amount to be deducted from the benefits otherwise due each person subject to the deduction.
D. In 2003 Section 627.739(2) was amended to provide in pertinent part:
Insurers shall offer each applicant and to each policyholder, upon the renewal of an existing policy, deductibles, in the amounts of $250, $500, and $1000. The deductible amount must be applied to 100 percent of the expenses and losses described in S.627.736. After the deductible is met, each insured is eligible to receive up to $10,000 in total benefits described in S.627.736(1).
E. The 2003 amendment made it clear that the deductible did not reduce the total amount of the benefit which was available to the insured.
F. The Legislature made an additional modification when it included the language: “The deductible amount must be applied to 100 percent of the expenses and losses described in S.627.736.” Plaintiff contends this means 100 percent of the amount billed by the treatment provider. Defendant contends this means 100 percent (as opposed to the 80 percent) of “reasonable expenses” defined by S.627.736.
G. In order to understand what the legislature meant one needs only to look at the applicable portion of the referenced statute — section 627.736(1)(a) which sets forth the amount of “medical benefits” which must be covered and must be paid. The statute in 2003 and 2016 are the same: “Eighty percent of all reasonable expenses for medically necessary medical, X-ray, . . . .” When the legislature added the sentence: “The deductible amount must be applied to 100 percent of the expenses and losses described in S.627.736” the legislature was modifying the “eighty percent of all reasonable expenses.” Thus, the amount to be paid is “eighty percent of all the reasonable expense,” but the amount of the deductible is calculated using one hundred percent of all reasonable expenses.
H. The Plaintiff’s interpretation says that the “100 percent” applies to the entire bill submitted by the provider. Such an interpretation would allow a provider that (who in this case and most others) accepts an assignment of benefits to bill any amount they wanted for any treatment of the insured regardless of its reasonableness. This would literally allow, without recourse, the assignee medical provider to determine when PIP benefits would begin. This cannot be what the legislature intended.
Therefore, it is,
ORDERED AND ADJUDGED:
1. The Plaintiff’s Motion for Summary Judgment is Denied.
2. The Defendant’s Motion to Dismiss is Granted to the extent it is consistent with this Court’s finding.
