24 Fla. L. Weekly Supp. 890b
Online Reference: FLWSUPP 2410ALFOInsurance — Personal injury protection — Coverage — Deductible — Clear and unambiguous language of PIP statute and PIP policy do not allow insurer to make any reductions to bills applied to deductible
PANHANDLE ORTHOPAEDICS, LLC, a/a/o Garrett Alford, Plaintiff, v. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COWE 15-009174 (83). January 10, 2017. Ellen Feld, Judge.
ORDER DENYING DEFENDANT’S MOTION FORSUMMARY JUDGMENT AND GRANTING PLAINTIFF’SCROSS MOTION FOR SUMMARY JUDGMENT
THIS CAUSE having come before the Court for hearing on December 9, 2016, on Defendant’s Motion for Final Summary Judgment and Plaintiff’s Cross Motion for Summary Judgment, and the Court having reviewed the Motion, the entire Court file, the relevant legal authorities, having heard argument of counsel, having made a thorough review of the matters filed of record, and being sufficiently advised in the premises, the Court finds as follows:
FINDINGS OF FACT
The Plaintiff brought this action against the Defendant alleging breach of contract for failure to pay personal injury protection benefits for treatment rendered to Garrett Alford as a result of a December 22, 2012 motor vehicle accident. Plaintiff rendered treatment to Garrett Alford on January 4, 2013 and January 8, 2013. Plaintiff submitted properly completed bills for medically necessary and reasonable treatment provided to Garrett Alford. Plaintiff filed the affidavit of Dr. Michael Gilmore, M.D. in support of the reasonableness and medical necessity of the subject treatment as well as the reasonableness of the amount billed by the Plaintiff. Defendant did not file any evidence in opposition. Defendant received three bills prior to the receipt of the bills from the Plaintiff. Defendant received a bill from North Okaloosa Medical Center in the amount of $4,857.00, a bill from West Florida Radiology in the amount of $201.60, and a second bill from North Okaloosa Medical Center in the amount of $76.88. Defendant issued a policy of insurance which covered Garrett Alford and contained a $1,000.00 deductible. Defendant did not make payment for any of the bills received and limited all of the charges to Florida Statute Section 627.736(5)(a)(2) and applied the deductible to all of the bills after a reduction to the permissive schedule of maximum charges. Plaintiff argued the Defendant was required to apply the deductible to the full amount of the charge in the order the bills are received. Defendant argued that it was required to reduce all of the bills to the permissive schedule of charges and then apply the deductible to the bills.
FINDINGS OF LAW
This Court finds that the clear and unambiguous language of Florida Statute Section 627.739 and the subject policy language do not allow the Defendant to make any reductions to the bills that are applied to the deductible. This Court is required to enforce the plain meaning of an unambiguous statute. Shelby Mutual Insurance Company v. Smith, 556 So. 2d 393 (Fla. 1990). This Court finds the relevant provisions of the statute are clear and unambiguous. Florida Statute Section 627.739 specifically provides that the deductible is to be applied to “100 percent of the expenses and losses described in s. 627.736.” Fla. Stat. § 627.739(2012).
Further, Defendant’s policy of insurance does not allow Defendant to reduce the bills prior to applying the bills to the deductible. Defendant’s policy of insurance does not contemplate any reductions until a payment is made by the Defendant. Specifically, Defendant’s policy provides:
“The deductible is to be applied to 100% of the expenses and losses covered under Personal Injury Protection Coverage. After the deductible is met, each insured person is eligble to receive up to $10,000.00 in total benefits under Personal Injury Protection Coverage.” (Page 10 of Defendant’s Policy of Insurance).
“UNREASONABLE OR UNNECESARY MEDICAL BENEFITS — If an insured person incurs medical benefits that we deem to be unreasonable or unnecessary, we may refuse to pay for those medical benefits and contest them.” (Endorsement — A041 FL (06/11)(emphasis added)
Progressive’s endorsement further provides, “We will limit reimbursement to, and pay no more than, 80 percent of the following schedule of maximum charges.” (Endorsement — A041 FL (06/11)(emphasis added)
Defendant’s argument fails as the specific policy language cited above by the Defendant only applies in a situation where Defendant makes a payment under the policy. Further, this court finds Defendant’s other arguments unpersuasive as well. Defendant’s reliance on General Star Indemnity Company v. West Florida Village Inn, Inc., 874 So. 2d 26 (Fla. 2d DCA 2004) [29 Fla. L. Weekly D1070b] is misplaced. The General Star cases stands for the proposition that non-covered or excluded losses are not applied to satisfy the deductible. The Court in General Star did not have a clear and unambiguous statute such as 627.739 which clearly indicates the deductible is to be applied to 100% of the expenses and losses. Further, Defendant’s policy and Defendant’s arguments contradict each other with respect to a lawsuit by the medical provider against the insured for any amounts not covered by Defendant’s reductions prior to application of the deductible. Defendant’s policy of insurance specifically excludes indemnifying the insured for any reductions made under the permissive fee schedule.CONCLUSION
Florida Statute Section 627.739 is clear, the Defendant is required to apply the deductible to the full amount charged prior to making any reductions to the subject bills. The undisputed facts and evidence before this Court demonstrate that Defendant improperly applied the deductible to the Plaintiff’s bills for treatment rendered on January 4, 2013 and January 8, 2013.
IT IS THEREFORE ORDERED AND ADJUDGED that Defendant’s Motion for Final Summary Judgment is hereby DENIED. Plaintiff’s Cross Motion for Final Summary Judgment is GRANTED.
