25 Fla. L. Weekly Supp. 272a
Online Reference: FLWSUPP 2503LEGEInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Clear and unambiguous election by insurer — PIP policy and endorsement, when read together, clearly and unambiguously elect to limit reimbursement to permissive statutory fee schedules
ADVANCED 3-D DIAGNOSTIC, INC., a/a/o Jean G. Leger, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 2015-SC-011196-O. January 13, 2017. Jeanette D. Bigney, Judge.
ORDER GRANTING DEFENDANT’S AMENDEDMOTION FOR FINAL SUMMARY JUDGMENT
The Defendant’s Amended Motion For Final Summary Judgment, having come to be heard by this Court on Wednesday, August 17, 2016, having reviewed the pleadings, heard argument of counsel and being otherwise fully advised in the premises, the Court hereby finds as follows:PARTIES
Defendant State Farm Mutual Automobile Insurance Company is the moving party. Attorney Eric V. Tourian of the law firm of Kubicki Draper, P.A., argued the Defendant’s Amended Motion For Final Summary Judgment. The Plaintiff’s position was argued by Attorney Joshua Meadow of The Law Offices Of Jason B. Giller, P.A.
FACTS
The Plaintiff filed its Complaint with the Court on September 19, 2015. The Plaintiff’s Complaint alleges that Claimant Jean G. Leger was involved in an automobile accident on April 22, 2013.
It is undisputed that, at the time of the loss, Claimant Jean Leger was insured under a policy of No-Fault (“PIP”) insurance issued by State Farm Mutual Automobile Insurance Company. The Court finds that the subject policy was composed of policy form 9810.7 with the 6910.3, 6127HH and 6126LS endorsements. The aforementioned policy form and endorsements (the “Policy”) were in full force and effect on the date of the subject accident. The Policy provided for $10,000.00 in No Fault (PIP) Benefits. The Policy did not provide Medical Payments Coverage Benefits.
It is undisputed that Claimant Jean G. Leger had x-rays of his cervical, thoracic and lumbar spine on May 2, 2013. The cervical x-ray was coded with CPT Code 72040 and was billed in the amount of $200.00. The thoracic x-ray was coded with CPT Code 72070 and was billed in the amount of $200.00. The lumbar x-ray was coded with CPT Code 72100 and was billed in the amount of $200.00.
It is further undisputed that thereafter Claimant Jean G. Leger had an MRI of his lumbar spine on May 31, 2013. The lumbar MRI was coded with CPT Code 72148 and was billed in the amount of $1,600.00. The Plaintiff asserts that Jean G. Leger assigned his right to sue to the Plaintiff.
The Defendant received the Plaintiff’s bills for the cervical, thoracic and lumbar x-rays on June 3, 2013. The Defendant thereafter paid the three x-ray CPT Codes at a rate of 200% of the 2007 Medicare Part B Fee Schedule and then paid 80% of the allowed amount.
More specifically, Defendant paid the Plaintiff’s bill for the May 2, 2013 x-rays as follows:
Cervical x-ray = $200.00 billed; limited to an allowed amount of $75.22 which is 200% of the 2007 Medicare Part B Fee Schedule; $75.22 x 80% = $60.18, total amount reimbursed.
Thoracic x-ray = $200.00 billed; limited to an allowed amount of $75.22 which is 200% of the 2007 Medicare Part B Fee Schedule; $75.22 x 80% = $60.18, total amount reimbursed.
Lumbar x-ray = $200.00 billed; limited to an allowed amount of $79.88 which is 200% of the 2007 Medicare Part B Fee Schedule; $79.88 x 80% = $63.90, total amount reimbursed.
Total Amount Reimbursed by State Farm for the May 2, 2013 date of service = $184.26.
The Defendant thereafter received the Plaintiff’s bill for the lumbar MRI on July 16, 2013. The Defendant thereafter allowed the MRI at a rate of 200% of the 2007 Medicare Part B Fee Schedule and then paid 80% of the allowed amount.
More specifically, Defendant paid the Plaintiff’s bill for the May 31, 2013 MRI as follows:
Lumbar MRI = $1,600 billed; limited to an allowed amount of $1,164.92 which is 200% of the 2007 Medicare Part B Fee Schedule; $1,164.92 x 80% = $931.94, total amount reimbursed.
Total Amount Reimbursed by State Farm for the May 31, 2013 date of service = $931.94.
NATURE OF THE DISPUTE
The Plaintiff asserts that when the subject insurance contract is read as a whole, the subject contract does not permit Defendant to limit payment based on the schedule of maximum charges in Fla. Stat. §627.736(5)(a) and that its bill should have been paid at 80% of the face amount of the bill.
The Defendant asserts that the subject insurance contract does unambiguously and clearly limit payment based on the schedule of maximum charges in Fla. Stat. §627.736(5)(a) and that the Plaintiff’s bill was paid in full. The Defendant further argued that the Florida Supreme Court ruling in Geico Ins. Co. v. Virtual Imaging Servs., Inc., 141 So. 3d 147 (Fla. 2013) [38 Fla. L. Weekly S517a] does not mandate the manner or form in which the insured must be notified that the schedule of maximum charges will be utilized. Defendant also directed the Court’s attention to the Second District Court of Appeals’ ruling in Allstate Indemnity Co. v. Markley Chico & Acupuncture, LLC, ___ So. 3d ___ 2016 WL 1238533 (Fla. 2nd DCA 2016) [41 Fla. L. Weekly D793b].
RULING
The Court has very carefully reviewed the pleadings and the authorities submitted by both the Plaintiff and Defendant. After considering all the relevant materials, the Court finds that the contractual language in this case is similar to the language approved by the Second DCA in Markley. The Court also finds that, as a matter of law, Virtual Imaging Servs., does not dictate the form of notice which must be provided in an insurance policy in order for an insurer to limit payment based on the schedule of maximum charges found in Fla. Stat. §627.736(5)(a). The Court finds that, when 9810.7 policy 6126LS endorsement are read together, there is no doubt that the Policy clearly and unequivocally notifies the insured(s) of State Farm’s intention to limit maximum reimbursement by application of the schedule of maximum charges in Fla. Stat. §627.736(5)(a). Therefore, the Defendant paid the CPT codes in accordance with the terms and conditions of the subject insurance policy.
THEREFORE it is ORDERED AND ADJUDGED that the Defendant’s Motion For Final Summary Judgment is GRANTED and the Plaintiff shall take nothing from this action, and the Court reserves jurisdiction to order the payment of fees and costs if appropriate.
