24 Fla. L. Weekly Supp. 828c
Online Reference: FLWSUPP 2410PALMInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Policy clearly and unambiguously permitted insurer to limit reimbursement by reference to schedule of maximum charges — Insurer paid charges submitted by provider at appropriate reimbursable amount pursuant to policy
ORTEGA CHIROPRACTIC CORP., a/a/o Robert and Lisa Palmer, A FLORIDA CORPORATION, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, INC., A FOREIGN CORPORATION, Defendant. County Court, 7th Judicial Circuit in and for Volusia County. Case No. 2014-31486-COCI. June 29, 2016. Angela A. Dempsey, Judge.
ORDER GRANTING DEFENDANT’S MOTION FORPARTIAL SUMMARY JUDGMENT PURSUANTTO 9810A POLICY
THIS CAUSE having come before the Court on the Motion of Defendant, State Farm Mutual Automobile Insurance Company (“State Farm”) for Motion for Partial Summary Judgment and this Honorable Court having considered the motion, the case law presented, the record and the arguments of counsel on June 3, 2016, and being otherwise fully advised in the premises hereby GRANTS the Defendant’s Motion for Partial Summary Judgment and finds that Defendant State Farm Mutual Automobile Insurance Company properly limited reimbursement to Plaintiff based upon the application of the schedule of maximum charges set forth in its 9810A policy, which was properly before this court as summary judgment evidence, and Florida Statutes § 627.736(5)(2013); State Farm’s Policy is clear and unambiguous and permits it to limit reimbursement by reference to the schedule of maximum charges as a matter of law; and that State Farm paid the charges submitted by Plaintiff at the appropriate reimbursable amount pursuant to the Policy.
1. State Farm issued an insurance policy (the “Policy”) that provided Florida no-fault (“PIP”) benefits to Robert and Lisa Palmer, which was in full force and effect on the date of the alleged accident.
2. Lisa Palmer was involved in a motor vehicle accident on June 23, 2013 and Plaintiff, Ortega Chiropractic Corp. (“Ortega”), provided services to Mrs. Palmer from July 3, 2013 through August 5, 2013, for injuries allegedly sustained in the accident. Plaintiff asserted standing to sue based upon an assignment of benefits from Mrs. Palmer.
3. Plaintiff submitted bills to State Farm for services in connection with its treatment of Mrs. Palmer.
4. In making payment, State Farm paid a reasonable amount and 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.
5. State Farm’s 9810A Policy expressly limits State Farm’s obligation to pay a reasonable amount by reference to the Schedule of Maximum Charges and notifies policyholders (and their provider assignees) that State Farm will limit payment based on the application of the Schedule of Maximum Charges.
6. The Court finds that, consistent with this Policy language, State Farm properly limited reimbursement to Plaintiff based upon the application of the schedule of maximum charges set forth in Florida Statutes § 627.736(5)(2013).
7. The Court finds 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. With the exception of CPT Code 99202 which was denied by State Farm and subject to a separate summary judgment Order, the Court finds that State Farm paid the charges submitted by Plaintiff for dates of service July 3, 2013 through August 5, 2013 as identified in Plaintiff’s Complaint at the appropriate reimbursable amount pursuant to the Policy.
9. The Court Grants Partial Summary Judgment in favor of Defendant, State Farm Mutual Automobile Insurance Company for dates of service July 3, 2013 through August 5, 2013; however, CPT Code 99202 for date of service July 3, 2013 is subject to a separate summary judgment Order due to unbundling.
