25 Fla. L. Weekly Supp. 112a
Online Reference: FLWSUPP 2501COOPInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Clear and unambiguous election by insurer — PIP policy that states that insurer will determine to be unreasonable any charges that exceed schedule of maximum charges and will limit reimbursement to 80% of schedule of maximum charges provides notice that insurer will limit reimbursement to statutory fee schedule and allows insurer to apply Medicare payment methodologies, including Multiple Procedure Payment Reduction, to determine appropriate amount under fee schedule — Deductible — Insurer properly applied statutory fee schedule to bills before applying resulting amount to deductible
DR. ANTHONY CARUSO, P.A. a/a/o Russell Cooper, Plaintiff, v. PROGRESSIVE SELECT INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County, Civil Division. Case No. 502016SC004422XXXXMB (RF). March 7, 2017. Frank S. Castor, Judge. Counsel: Matthew N. Grosswald and Theophilos Poulopoulos, Schiller, Kessler & Gomez, PLC, Fort Lauderdale, for Plaintiff. Brian S. Goldstein and Patrick J. Gerace, Progressive PIP House, Fort Lauderdale, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FORFINAL SUMMARY JUDGMENT AND DENYINGPLAINTIFF’S AMENDED RESPONSE AND MOTIONFOR FINAL SUMMARY JUDGMENT
THIS CAUSE having come before the Court on March 3, 2017, pursuant to Defendant’s Motion for Final Summary Judgment and Plaintiff’s Amended Response and Motion for Final Summary Judgment, and the Court having reviewed the record evidence, pleadings, and motions, and having considered argument of Counsel and legal authority submitted by the parties, and being otherwise fully advised in this matter, does hereby make the following findings of fact and conclusions of law:
FINDINGS OF FACT
At the time of the alleged accident on October 4, 2015, the claimant was insured by an automobile insurance policy contract for 9611D (07/13); issued on July 18, 2015 for coverage dates July 18, 2015 through January 18, 2016. The policy included $10,000 in personal injury protection benefits and a $1,000 deductible. Defendant received bills for treatment from Plaintiff, DR. ANTHONY CARUSO, P.A., for dates of service October 14, 2015 through December 18, 2015. Defendant applied 100% of the charges covered under the policy to the deductible. Defendant reduced the charges pursuant to F.S. § 627.736(5)(a)(1-5) and the policy of insurance before applying the deductible. The amount Defendant allowed was based on 200% of the Medicare Part B fee schedule for the region in which the services were rendered. The amounts allowed reflected a reduction of the practice expense component for selected therapy services [secondary procedure codes subject to the Medicare Multiple Procedure Payment Reduction (“MPPR”) rule]. If the allowed amount for the secondary procedure code was less than 200% of the amount set forth in the 2007 Participating Level of the Medicare Part B fee schedule, the Defendant allowed the code at the higher 2007 amount. Plaintiff filed a Complaint for Breach of Contract against Defendant alleging that Defendant failed to pay all amounts owed for PIP benefits.
ANALYSIS AND CONCLUSIONS OF LAW
This Court finds that Defendant has properly incorporated the fee schedules and payment methodologies found in F.S. § 627.736(5)(a)(1-5). This Court finds that Defendant’s policy complies with the notice require of F.S. § 627.736(5)(a)(5). Allstate Insurance Company v. Orthopedic Specialists, etc. 42 Fla. L. Weekly S39a (Fla. 2017), and that Defendant may use the fee schedules and payment methodologies to determine the appropirate amount of reimbursement.
Plaintiff presented the Court with a recent ruling in the matter of Hess Spinal & Medical Center, Inc. a/a/o Stefan Ilev v. Progressive American Insurance Company, Case No. 15-CC-16500(L) (Fla. 13th Jud. Cir. 2016), for the proposition that Defendant’s policy of insurance is ambiguous because medical benefits is defined as eighty (80%) percent of all reasonable expenses incurred for medically necessary services. Plaintiff further argues that Defendant’s policy is ambiguous because it does not define reasonable expenses. This interpretation ignores the operative portion of the policy pertaining to PIP coverage which states that Defendant will determine to be unreasonable any charges incurred that exceed the schedule of maximum charges, and that the Defendant will limit reimbursement to and pay no more than eighty (80%) percent of the schedule of maximum charges.1 This Court disagrees with ruling in Hess, and finds that Allstate Insurance Company v. Orthopedic Specialists, etc. 42 Fla. L. Weekly S39a (Fla. 2017) is controlling.2 This Court finds that F.S. § 627.736(5)(a)(3) permit insurers to reimburse claims consistent with Medicare payment methodologies. This Court finds that once a policy provides notice that it will limit reimbursement to the fee schedules, the insurer is permitted to apply MPPR in determining the appropriate amount under the fee schedule. This Court further finds that Defendant’s policy provides clear notice that it may apply MPPR. Further, this Court finds that MPPR is a payment methodology and not a utilization limit.
Plaintiff argues that Defendant has improperly utilized the fee schedules and payment methodologies for services which were applied to the $1,000.00 deductible under the policy. This Court finds that the Defendant properly applied the deductible pursuant to §627.739, Fla. Stat (2008) and § 627.736, Fla. Stat. (2013)3. Section 627.739, Fla. Stat. requires a cross-reference to § 627.736, for charges that fall within the deductible elected in the policy of insurance4. The deductible is a basic part of the insurance policy5, which requires a reasonableness analysis pursuant to the policy.6 Thus, Defendant appropriately applied the covered charges to the policy deductible. This Court disagrees with the Plaintiff’s analysis that the deductible should be applied to the provider’s billed amount.
Plaintiff contends that medical benefits are not the same as medical expenses. This Court disagrees with that analysis. Medical benefits refer to services being reasonable, related and necessary. This supports the Defendant’s position that a reasonableness analysis must occur prior to the application of the deductible and that the deductible only applies to covered expenses. This Court finds when proper notice is provided the fee schedules and payment methodology limitations apply to all charges, including those applied to the deductible.
ORDERED AND ADJUDGED that Defendant’s Motion for Final Summary Judgment be, and the same is hereby GRANTED and Plaintiff’s Amended Response and Motion for Final Summary Judgment is hereby DENIED. Plaintiff shall take nothing by this action.
FINAL SUMMARY JUDGMENT IS HEREBY ENTERED IN FAVOR OF THE DEFENDANT AND IT SHALL GO HENCE FORTH WITHOUT DAY. The Defendant is the prevailing party in this action. The Court reserves jurisdiction to determine Defendant’s entitlement to reasonable attorneys’ fees and costs.
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1See Miglino v. Universal Property and Casualty Ins. Co., 174 So.3d 479 (Fla. 4th DCA 2015) [40 Fla. L. Weekly D1910a] (“. . .the lack of a definition of a term in a policy does not render it ambiguous or in need of interpretation by the courts, but rather such ‘the terms must be given their everyday meaning and should be read with regard to ordinary people’s skills and experience.’ ”)
2See Barcelona Hotel, LLC v. Nova Casualty Co., 57 So.3d 228 (Fla. 3rd DCA 2011) [36 Fla. L. Weekly D458a] (“. . . in construing insurance policies courts should read each policy as a whole endeavoring to give every provision its full meaning and operative effect.”)
3This Court finds that the relevant version to cross reference is §627.736, Fla. Stat (2013) as there is clear Legislative intent as to what constitutes covered benefits under this version of the statute, i.e., “medical benefits do not include massage. . . .”
4See Mercury Ins. Co. of Florida v. Emergency Physicians of Cent., 182 So.3d 661 (Fla. 5th DCA 2015) [40 Fla. L. Weekly D2364a].
5See Digital Medical Diagnostics a/a/o Jesus Gaber, Miriam Gaber, and Lidice Soto v. United Auto. Ins. Co., 958 So.2d 505 (Fla. 3rd DCA 2007) [32 Fla. L. Weekly D1392a].
6See Garrison Prop. & Cas. Ins. Co. v. New Smyrna Imaging, LLC, Case No. 13-03-AP (18th Cir. App. 2015) [23 Fla. L. Weekly Supp. 708a], and Progressive American Ins. Co. v. Munroe Regional Health System Inc. d/b/a Munroe Regional Medical Center, Case No. 14-11-AP (18th Cir. App. 2015) [23 Fla. L. Weekly Supp. 707a]
