25 Fla. L. Weekly Supp. 554a
Online Reference: FLWSUPP 2506DUDLInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Clear and unambiguous election by insurer — PIP policy that states that insurer will pay 80% of 200% of allowable amount under participating physician fee schedule of Medicare Part B clearly and unambiguously elects to limit reimbursement to permissive statutory fee schedule — Policy containing general references to coding policies and procedures does not clearly elect use of multiple procedure rule to reduce payment below permissive statutory fee schedule
MILLENNIUM RADIOLOGY LLC (a/a/o Saloma Dudley), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami Dade County. Case No. 14-3280-SP 23 (3). February 29, 2016. Linda Singer Stein, Judge.
REVERSED. FLWSUPP 2712DUDL
FINAL JUDGMENT AND ORDER GRANTINGPLAINTIFF’S MOTION FOR SUMMARYJUDGMENT AND DENYING DEFENDANT’SMOTION FOR SUMMARY JUDGMENT
THIS CAUSE came before the Court on February 22, 2016, concerning: (1) the “Plaintiff’s Motion for Final Summary Judgment” filed on November 17, 2014, and (2) the “Defendant’s Cross Motion for Final Summary Judgment” filed on September 15, 2015. The Court, having considered the motion, the arguments of counsel, and the record, and being otherwise advised in the premises, GRANTS the Plaintiff MILLENNIUM RADIOLOGY LLC’s Motion for Final Summary Judgment and DENIES the Defendant State Farm Mutual Automobile Insurance Company’s Cross Motion for Final Summary Judgment. Accordingly, it is hereby
ORDERED AND ADJUDGED as follows:
Findings of fact
This is a personal injury protection (“PIP”) case, where the Plaintiff seeks damages for unpaid no-fault benefits. The Defendant admits that the assignor was covered at the relevant time under a policy issued by State Farm, and that the policy was in full force and effect. The Defendant has stipulated to the relatedness and medical necessity of the services at issue. The Parties agree that the total amount claimed due by the Plaintiff represents 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule amounts for the services at issue. The Defendant filed State Farm’s 9810A policy form, and the parties agree that it is the operative policy in this case.
In support of its argument, the Defendant provided opinions from the cases of Multicare Rehabilitation LLC v. Progressive Select Ins. Co. Case No. COCE 14-022054 (50), (Fla. 17th Cty. Ct. 2016) [24 Fla. L. Weekly Supp. 171a]; and SOCC PL v. Progressive American Ins. Co., Case No. 15-CC-015856 (M) (Fla. 13th Cty. Ct. 2016) [24 Fla. L. Weekly Supp. 163b]. This Court finds that State Farm’s 9810A policy is distinguishable from the policies at issue in those cases, which are not persuasive in this case.
Findings of law:
The Court has previously ruled on the legal issues presented herein, in Pan Am Diagnostic Services Inc. v. State Farm, Cases No. 14-3289 SP 23(3) and 14-3283 SP 23 (3) [23 Fla. L. Weekly Supp. 855a]. As in those cases, this Court holds that State Farm’s 9810A policy is clear and unambiguous in its election to pay pursuant the 2007 Medicare Part B participating physicians fee schedule. At page 16, State Farm’s policy clearly elects to pay “For all other medical services. . . .200 percent of the allowable amount under: (I) The participating physicians fee schedule of Medicare Part B. . .”; and further states: “The applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect on March 1 of the year in which the services, supplies of care are rendered, and for the area. . . .except that it will not be less than the allowable amount under the applicable schedule of Medicare Part B for 2007. . . . .”.(emphasis added). That language is patent on the face of the policy.
The general references to Medicare coding policies and procedures, on page 5 and 16 of the policy are vague and ambiguous, do not override the clear language cited above, and do not clearly and unambiguously elect any other identifiable reimbursement methodology beyond the 80% of 200% of the 2007 Medicare Part B Physicians Fee Schedule method. The Defendant’s policy does not clearly elect the Medicare Multiple Procedure Rule (MPPR) and does not permit Defendant to limit reimbursement to less than 80% of the allowable amount under the 2007 Medicare Part B physicians’ fee schedule. The policy clearly and unambiguously elects the 200 Percent of the Medicare Part B Fee schedule method of reimbursement. Accordingly, the Plaintiff’s Motion for Final Summary Judgment is hereby GRANTED, and the Defendant’s Cross Motion for Final Summary Judgment is hereby DENIED.
ORDERED AND ADJUDGED that
Plaintiff’s Motion for Final Summary Judgment is GRANTED. Final Judgment is hereby entered in favor of the Plaintiff, MILLENNIUM RADIOLOGY LLC, as assignee of Saloma Dudley, against the Defendant, State Farm Mutual Automobile Insurance Company, whose address is One State Farm Plaza, Bloomington, IL 61710, in the total amount of $290.85, plus applicable prejudgment and post judgment interest, for which let execution issue forthwith.
The Court finds Plaintiff to be the prevailing party herein, and so entitled to attorney’s fees and costs pursuant to FS 627.428, and reserves jurisdiction to establish the amount of such attorney’s fees and costs.
