25 Fla. L. Weekly Supp. 807a
Online Reference: FLWSUPP 2509STOKInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedule — Clear and unambiguous election by insurer — Policy at issue provided clear and unambiguous notice of insurer’s intent to limit reimbursement to the schedule of maximum charges found in No-Fault Law, including use of Medicare coding policies and payment methodologies
FIRST COAST MEDICAL CENTER, INC. a/a/o Frankie Stokes a/a/o Larry Holm, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 4th Judicial Circuit in and for Duval County. Case No. 16-2016-SC-3608-XXXX-MA, DIVISION I. August 31, 2017. Pauline M. Drake, Judge.
ORDER GRANTING DEFENDANT’SMOTION FOR SUMMARY JUDGMENT
This Court held a hearing on Defendant’s Motion for Summary Judgment and Plaintiff’s Countermotion for Summary Judgment on August 28, 2017.
Defendant in this case filed a Motion for Summary Judgment, contending that it paid to Plaintiff in full $5,869.09 for covered medical expenses. That amount equals eighty percent (80%) of the total allowable medical expenses set forth in Fla. Stat. § 627.736(5)(a)1(2013).
Plaintiff in this case filed a Countermotion for summary judgment, contending that it was underpaid. Plaintiff argues that Defendant’s payment of $5,869.09 reflect the amount permitted under the Medicare fee schedule, but Defendant is not allowed to use that methodology for payment because the insurance policy did not place the insured on notice in clear and unambiguous terms that it elected to use the Medicare fee schedule method.
Plaintiff contends that defining reasonable fees and also limiting the maximum amount of payment by following the Medicare fee schedule is “commingling” and runs afoul Fla. Stat. 627.736(5)(a)5 and Geico v. Virtual Services, 141 So.3d 147 (2013) [38 Fla. L. Weekly S517a]. Geico does not apply to this case. In Geico, the Court ruled “our holding applies only to policies that were in effect from the effective date of the 2008 amendments to the PIP statute that first provided for the Medicare fee schedule methodology, which was January 1, 2008, through the effective date of the 2012 amendment, which was July 1, 2012.” The insurance policy in instant case was written after July 1, 2012. Fla. Stat. 627.746(5)(a)5 allows an insurance provider to limit payment based on the Medicare fee schedule as long as notice is provided in the policy. Defendant clearly and plainly gave notice of its election to limit maximum payment based on the fee schedule. The insurance policy reads “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. . .”
The Florida Supreme Court held that where language in an insurance contract is plain and unambiguous, a Court must interpret the policy in accordance with the plain meaning so as to give effect to the policy as written. Allstate Ins. Co. v. Orthopedic Specialists, 212 So.3d 973 (Fla. 2017) [42 Fla. L. Weekly S38a]. The terms of the insurance contract in instant case are clear, unambiguous, and must be interpreted with the plain meaning as written. The insurance contract plainly states the limits of its payments in the contract.
This Court cannot find any ambiguity or lack of notice in those terms. The parties clearly contracted for a maximum amount to be paid based on the No-Fault Act. Plaintiff agrees that Defendant paid that amount.
Therefore, this Court finds that Defendant paid Plaintiff in full, Defendant’s Motion for Summary Judgment is GRANTED, and the Plaintiffs Motion for Summary Judgment is DENIED.
