25 Fla. L. Weekly Supp. 107d
Online Reference: FLWSUPP 2501PICAInsurance — Personal injury protection — Coverage — Medical expenses — Where definition of “reasonable charge” in PIP policy is hybrid of factors found in reasonable amount method of reimbursement and provisions from fee schedule method of reimbursement, policy is ambiguous as to reimbursement method and did not specifically elect fee schedule method of reimbursement — Approval of PIP policy form by Office of Insurance Regulation does not override requirement that policy provide insured with notice of election of one of two payment methodologies
CRESPO & ASSOCIATES, P.A., a.a.o. Albert Picallo, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 16-CC-003496. March 7, 2017. Daryl M. Manning, Judge. Counsel: David M. Caldevilla, de la Parte & Gilbert, P.A., Tampa; and Anthony T. Prieto, Prieto, Prieto, & Goan, P.A., Tampa, for Plaintiff. Anthony Parrino, Reynolds Parrino Spano & Shadwick, P.A., St. Petersburg, for Defendant.
ORDER ON COMPETING MOTIONS FOR SUMMARYJUDGMENT CONCERNING STATE FARM POLICY FORM 9810A
THIS MATTER came before the Court at a hearing on September 22, 2016, concerning Defendant, State Farm Mutual Automobile Insurance Company’s (“State Farm”) Motion for Summary Judgment and Memorandum of Law in Support filed on April 29, 2016, and Plaintiff, Crespo and Associates P.A.’s (“Crespo”) Motion for Summary Judgment on Count I in Response to Defendant’s Motion for Summary Judgment filed on August 22, 2016. Having considered the motions, the arguments of counsel, the record, and the admissible evidence, the Court finds:
1. Both motions for summary judgment pertain to the parties’ respective rights and obligations concerning State Farm Policy Form 9810A and Florida Statutes section 627.736 (2012-2016).
2. This Court agrees with the persuasive decisions presented by the Plaintiff and finds that State Farm’s Policy Form 9810A improperly adopts a hybrid payment methodology that incorporates elements from both the Medicare Fee Schedule Method described in Florida Statutes section 627.736(5)(a)1-5 and the fact-dependent Reasonable Amount Method described in Florida Statutes section 627.736(5)(a). See Order Granting Plaintiff’s Motion for Summary Judgment as to Count I of Complaint, Crespo & Associates, P.A., a.a.o. Debra Thompson v. State Farm Mutual Automobile Insurance Co., (Fla. Hillsborough Cty. Ct. Sept. 19, 2016) (Case No. 16-CC-3030); Crespo & Associates, P.A. a.a.o. Veronica Rondon v. State Farm Mutual Automobile Insurance Co., 23 Fla. L. Weekly Supp. 982b (Fla. Hillsborough Cty. Ct. Dec. 18, 2015); Order Granting MRI Associates, Inc.’s Motion for Final Summary Judgment, and Denying State Farm Mutual Automobile Insurance company’s Motion for Final Summary Judgment, State Farm Mutual Automobile Insurance Co. v. MRI Associates of Tampa, Inc., (Fla. 13th Jud. Cir. Ct. Aug. 18, 2016) (Case No. 14-CA-8634); University Community Hosp. a/a/o v. Mercury Insurance Company of Florida, 21 Fla. L. Weekly Supp. 89a (Fla. Hillsborough Cty. Ct., Sept. 16, 2013).
3. This Court finds the issue in this case to be distinguishable from that determined in the Allstate line of cases cited by Defendant in support of its Motion, including the Florida Supreme Court’s recent decision in Allstate Insurance Company v. Orthopedic Specialists, __So. 3d__, 2017 WL 372092 (Fla. Jan. 26, 2017) [42 Fla. L. Weekly S38a]. In contrast, to the matter presently before this Court, the cases cited by Defendant do not address or analyze the “reasonable charge” definition of Policy Form 9810A. Specifically, those cases do not address the implications of State Farm’s “reasonable charge” definition which commingles the elements of the fact-dependent reasonable amount method described in Florida Statutes section 627.736(5)(a) and the elements of the Medicare fee schedule method described in Florida Statutes section 627.736(5)(a)1-5.
4. As to the Defendant’s argument relative to the Office of Insurance Regulation’s (OIR) approval of State Farm’s Policy Form 9810A, this Court agrees with the analysis in Pathway Wellness Chiropractic Clinic v. State Farm Mutual Automobile Insurance Company, 24 Fla. L. Weekly Supp. 616a (Fla. Leon Cty. Ct. Sept. 21, 2016) and the cases cited therein. The OIR’s approval of the policy form does not override the requirement that State Farm’s policy provide the insured with notice of election of one of the two available payment methodologies.
Based on the foregoing, it is therefore ORDERED AND ADJUDGED:
1. Plaintiff’s Motion for Summary Judgment on Count I in Response to Defendant’s Motion for Summary Judgment filed on August 22, 2016 is hereby GRANTED.
2. Defendant’s Motion for Summary Judgment and Memorandum of Law in Support filed on April 29, 2016 is hereby DENIED.
3. With respect to the claim for declaratory relief set forth in Count I of the Plaintiff’s complaint, concerning the parties’ respective rights and obligations pursuant to Policy Form 9810A and Florida Statutes section 627.736 (2012-2016), this Court determines and declares as a matter of law:
a. State Farm has failed to clearly and unambiguously elect the Medicare Fee Schedule Method in Policy Form 9810A, and has instead adopted an unauthorized hybrid method comprised of elements from both the Medicare Fee Schedule Method described in Florida Statutes section 627.736(5)(a)1-5 (2012-2016) and the fact-dependent Reasonable Amount Method described in Florida Statutes section 627.736(5)(a) (2012-2016).
b. With respect to the Plaintiff’s PIP claims submitted under Policy Form 9810A, State Farm is required to pay such claims in accordance with the default Reasonable Amount Method, instead of the unauthorized hybrid method described in Policy Form 9810A or the Medicare Fee Schedule Method.
4. This Court reserves jurisdiction to determine Count II of the complaint, and any claims for reasonable attorneys’ fees and costs.
