25 Fla. L. Weekly Supp. 558a
NOT FINAL VERSION OF OPINION
Subsequent Changes at 26 Fla. L. Weekly Supp. 871aOnline Reference: FLWSUPP 2506JSANInsurance — Personal injury protection — Coverage — Medical expenses — Multiple Procedure Payment Reduction — Clear and unambiguous election by insurer — PIP policy containing general references to Medicare coding policies and procedures does not clearly elect use of Medicare MPPR rule to reduce payment below permissive statutory fee schedule
MILLENNIUM RADIOLOGY, LLC, d/b/a Mobile Imaging of America (a/a/o Jorge Sanchez), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 14-3281-SP 23 (3). November 28, 2016. Linda Singer Stein, Judge. Counsel: Yigal D. Kahana, Kahanalaw, P.A., North Miami. Omar A. Giraldo, Cole, Scott & Kissane, P.A., Plantation.
REVERSED. 26 Fla. L. Weekly Supp. 871a (State Farm Mut. Auto. Ins. Co. v. Millennium Radiology, LLC, Case No. 16-494 AP. 1-9-2019)
ORDER GRANTING PLAINTIFF’S MOTION FORSUMMARY JUDGMENT AND DENYING DEFENDANT’SCROSS-MOTION FOR SUMMARY JUDGMENT
THIS CAUSE came before the Court on Plaintiff’s Updated Motion for Final Summary Judgment, filed on March 3, 2016, and Defendant’s Cross-Motion for Summary Judgment, filed March 10, 2016. The Court, having considered the motions, the argument of counsel, the record, and being otherwise advised, GRANTS the Plaintiff Millennium Radiology LLC’s Motion for Final Summary Judgment and DENIES Defendant State Farm’s Cross-Motion for Summary Judgment.
FACTS
This is a personal injury protection (“PIP”) case, where the Plaintiff seeks damages for unpaid benefits. Plaintiff performed two MRIs, CPT code 72141, cervical, and CPT code 72148, lumbar, upon the assignor in this case, Jorge Sanchez, and timely sent Defendant a bill for same. The Defendant approved the claim in the amounts of $672.80 for CPT code 72141 and $1,206.66 for CPT code 72148, and paid 80% of the total approved amount for a total payment of $1,503.57. The Defendant admits that the assignor was covered at the relevant time under a policy it issued, which was then in full force and effect, and made a payment to Plaintiff of $1503.57 for two MRI exams, CPT Codes 72148 and 72141. The Defendant included that payment in its PIP payout log. The Defendant filed State Farm’s 9810A policy form, which the parties agree is the operative policy in this case.
The Plaintiff argues that Defendant’s 9810A policy form, at p. 16, clearly states that Defendant will pay 80% of “the allowable amount under (1) The participating physicians fee schedule of Medicare Part B except as provided in sub-sub-paragraphs (II) and (III).” The exceptions provided in sub-subparagraphs (II) and (III) do not apply. The policy further states that: “For purposes of the above, the applicable fee schedule or payment limitation in effect on March 1 of the year in which the services are rendered. . .except that it will not be less than the allowable amount under the applicable schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.”
The Defendant argues that there is also language on p. 16 of said policy stating: “We will limit payment of Medical Expenses described in the Insuring Agreement of this policy’s No-Fault Coverage to 80% of a properly billed and documented reasonable charge, but 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, including applicable modifier;” as well as on page 5, which states: “Reasonable Charge, which includes reasonable expense, means an amount to be determined by us to be reasonable in accordance with the No-Fault Act, considering one or more of the following: . . .Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services, including applicable modifiers, if the coding policy or payment methodology does not constitute a utilization limit.” Defendant argues that that language permits it to limit PIP reimbursements below the allowable amount under the 2007 Medicare Part B physicians fee schedule, based on a Medicare sub-schedule that allows for reduced payments when multiple procedures are performed at the same time (hereafter referred to as “MPPR”).
The Plaintiff filed suit for $154.27; the difference between 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule amount for the services at issue, and the amount paid by the Defendant. The Parties agree that the total amount claimed by the Plaintiff, $1,657.84, represents 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule.
FINDINGS OF LAW
The construction of an insurance policy is a question of law for the court. See Jones v. Utica Mut. Ins. Co., 463 So. 2d 1153, 1157 (Fla. 1985). Such contracts are interpreted in accordance with the plain language of the policy, and any ambiguities are liberally construed in favor of the insured and strictly against the insurer as the drafter of the policy. The Court finds the policy controls, and that Defendant’s 9810A policy does not clearly or specifically elect the MPPR. The general references regarding Medicare coding policies and procedures on pp. 5 and 16 of policy are vague and ambiguous, and do not clearly and unambiguously elect to pay pursuant to the MPPR.
Accordingly, it is ORDERED:
Final Judgment is hereby entered in favor of Plaintiff, Millennium Radiology LLC, as assignee of Jorge Sanchez, against the Defendant, State Farm Mutual Automobile Insurance Company, whose address is One State Farm Plaza, Bloomington, IL 61710, in the total amount of $154.27, 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.
