25 Fla. L. Weekly Supp. 283a

Online Reference: FLWSUPP 2503LROMInsurance — Personal injury protection — Deductible — Where insurer failed to provide clear and unambiguous notice of election to utilize permissive statutory fee schedules as method of calculating reimbursement, insurer improperly reduced charges through application of fee schedules before applying deductible to reduced amount

M&M MEDICAL CENTER, INC. (a/a/o Roman, Luis), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 12-10919 SP 23 (01). May 1, 2017. Myriam Lehr, Judge. Counsel: Robert B. Goldman, Florida Advocates, Dania Beach, for Plaintiff. Orlando H. Ortiz, House Counsel UAIC, for Defendant.

ORDER GRANTING PLAINTIFF’SMOTION FOR PARTIAL SUMMARYJUDGMENT REGARDING DEFENDANT’SMISAPPLICATION OF THE POLICY DEDUCTIBLE

THIS CAUSE having come before the Court on April 26, 2017, upon the motion of the Plaintiff, M&M Medical Center, Inc. (“M&M”) for Partial Summary Judgment on the issue of Defendant United Automobile Insurance Company’s misapplication of the $1,000 policy deductible, and the court having considered the summary judgment evidence, consisting of the Complaint, the Answer, Plaintiff’s Second Request for Admissions and admitted paragraphs thereto, having heard argument of counsel and being otherwise fully advised, it is

ORDERED that Plaintiff’s Motion for Partial Summary Judgment as to M&M’s misapplication of the deductible is GRANTED, based upon the following:

FINDINGS OF FACT

1. The United Automobile Insurance Company (“United Auto”) policy that affords coverage in this case (the “Policy”) contains a $1,000 deductible for PIP benefits.

2. The Policy provides that United Auto “will pay, in accordance with the Florida Motor Vehicle No-Fault Law, to or for the benefit of the injured person: (a) medical benefits — eighty percent of all medically necessary expenses”.

3. The Policy does not state that United Auto will calculate reimbursement amounts based upon the Medicare Part B Fee Schedule, 200% of the Medicare Part B Fee Schedule or the State Fee Schedule Guidelines.

4. After Luis Roman was injured as a result of an October 3, 2011 motor vehicle accident and treated with M&M, United Auto reduced M&M’s submitted charges to amounts equal to 200% of the Medicare Part B Fee Schedule, to which United Auto then applied the Policy’s $1,000 deductible.CONCLUSIONS OF LAW

13. § 627.739(2), Fla. Stat. (2011) provides:

Insurers shall offer to each applicant and to each policyholder, upon the renewal of an existing policy, deductibles, in amounts of $250, $500, and $1,000. The deductible amount must be applied to 100 percent of the expenses and losses described in s. 627.736. After the deductible is met, each insured is eligible to receive up to $10,000 in total benefits described in s. 627.736(1). However, this subsection shall not be applied to reduce the amount of any benefits received in accordance with s. 627.736(1)(c).

(Emphasis added).

14. The statute plainly requires the deducible to be applied to “100 percent of the expenses and losses described in s. 627.736.” This Court interprets that to mean that the deductible should be applied to “all expenses” and not just to “expenses that PIP pays”.

15. In M&M Medical Center, Inc. (a/a/o Alexandra Martinez) v. State Farm Mut. Auto. Ins. Co., 22 Fla. L. Weekly Supp. 378a (Miami-Dade County, October 9, 2013), this Court recognized that “the proper formulation for the subtraction of the deductible is to subtract it from the total billing amount before the reductions pursuant to section 627.736 are applied.”

16. A number of courts, including the Ninth and Twelfth Circuit Appellate Courts, also agree that “expenses” as used in the deductible statute means the total charge billed and requires the deductible to be applied to the total charge billed before application of any reimbursement limitations. Progressive Select Ins. Co. v. Florida Hospital Medical Center (a/a/o Jonathan Parent), 24 Fla. L. Weekly Supp. 318a (Fla. 9th Cir. App. Ct. 2016); Progressive Select Ins. Co. v. Florida Hospital Medical Center (a/a/o Louis Pena), 24 Fla. L. Weekly Supp. 200a (Fla. 9th Cir. App. Ct. 2016); Progressive American Ins. Co. v. Chambers Medical Group, Inc. (a/a/o Sheila Wilcox), Case No. 2015 SP 000850 NC (Fla. 12th Cir. App. Ct. 2016) [22 Fla. L. Weekly Supp. 743a]; David. A. Blum, M.D., P.A. (a/a/o Vanessa Moreno) v. Progressive Select Ins. Co., 24 Fla. L. Weekly Supp. 739a (Fla. Broward Cty. Ct. 2016); Care Wellness Center, LLC (a/a/o Virginia Bardon-Diaz) v. State Farm Mut. Auto. Ins. Co., 24 Fla. L. Weekly Supp. 383a (Fla. Broward Cty. Ct. 2016); C&R Healthcare, LLC (a/a/o Yonel Raphael) v. Security Nat’l Ins. Co., CONO 14-005982 (Fla. Broward Cty. Ct. 2016); Inline Chiropractic Group, Inc. (a/a/o Millward, Geoffrey) v. GEICO, 14-011297 CONO (72) (Fla. Broward Cty. Ct. 2016); Inline Chiropractic Group, Inc. (a/a/o Stroud, Jamie) v. GEICO, 14-012586 CONO (72) (Fla. Broward Cty. Ct. 2016); Wasserman Chiropractic, Inc. (a/a/o Sophia Adams) v. Mercury Indemnity Co. of America, 24 Fla. L. Weekly Supp. 462b (Fla. Broward Cty. Ct. 2016); Wasserman Chiropractic, Inc. (a/a/o Emma Adams) v. Mercury Indemnity Co. of America, 24 Fla. L. Weekly Supp. 467a (Fla. Broward Cty. Ct. 2016); Pagano Chiropractic, P.A. (a/a/o Davis Charles) v. Progressive American Ins. Co., 24 Fla. L. Weekly Supp. 467b (Fla. Collier Cty. Ct. 2016); Hyde Park Medical Center a/a/o Cheyenne Brown v. 21st Century Ins. Co. of California, 24 Fla. L. Weekly Supp. 310a (Fla. Duval Cty. Ct. 2016); USA Health & Therapy, Inc., (Garett Frazier) v. Security National Ins. Co., 23 Fla. L. Weekly Supp. 771a (Fla. Broward Cty. Ct. 2015); Altamonte Springs Diagnostic Imaging, Inc. D/B/A Mid Florida Imaging A/A/O Mariela Diaz v. Star Casualty Ins. Co., 23 Fla. L. Weekly Supp. 588a (Fla. Orange Cty. Ct. 2015); Excellent Health Care Services (a/a/o Edwin Martinez) v. Kingsway Amigo Ins. Co., 23 Fla. L. Weekly Supp. 168a (Fla. Miami Dade Cty. Ct. 2015); Asclepius Medical, Inc. (a/a/o Daisy Perez) v. Kingsway Amigo Ins. Co., 23 Fla. L. Weekly Supp. 167a (Fla. Miami Dade Cty. Ct. 2015); Naples HMA, LLC d/b/a Physicians Regional Medical Center- Collier Boulevard (a/a/o Triguero, Arai) v. State Farm Mut. Auto. Ins. Co., 22 Fla. L. Weekly Supp. 860a (Fla. Collier Cty. Ct. 2015); Tampa Bay Imaging, LLC (a/a/o Heather Dussault) v. Windhaven Ins. Co., 21 Fla. L. Weekly Supp. 436b (Fla. Hillsborough Cty. Ct. 2013); M & M Medical Center, Inc., (a/a/o Alexandra Martinez) v. State Farm Mut. Auto. Ins. Co., 22 Fla. L. Weekly Supp. 378a (Fla. Miami Dade Cty. Ct. 2013); William J. Gogan (a/a/o Tara Ricks) v. USAA General Indemnity Co., 21 Fla. L. Weekly Supp. 97c (Fla. Broward Cty. Ct. 2013); Flagler Hospital, Inc. (a/a/o Devin Sapp) v. Peak Property & Casualty Ins. Corp., 18 Fla. L. Weekly Supp. 597a (Fla. St. Johns Cty. Ct. 2011); and Flagler Hospital, Inc. (a/a/o Jody C. Rigdon) v. Progressive Select Ins. Co., 18 Fla. L. Weekly Supp. 620c (Fla. St. Johns Cty. Ct. 2011).

17. Although some courts have ruled that it is permissible to apply the deductible after statutory reductions, those cases have involved insurance policies where the insurer provided sufficient notice to the insured of its intention to use the statutory fee schedules to determine the reasonableness of medical expenses. See, e.g., Foundation for a Healthy St. Petersburg (a/a/o Cook Breanna) v. Direct Gen. Ins. Co., 24 Fla. L. Weekly Supp. 631b (Pinellas County, Judge Lorraine M. Kelly, Aug. 4, 2016); Advantacare of Florida (a/a/o Boucree, Blanca) v. GEICO Indemnity Co., 23 Fla. L. Weekly Supp. 841a (Volusia County, Judge Angela A. Dempsey, July 24, 2015); Royal Care Med. Center (a/a/o Samantha Gonzalez) v. Esurance Prop. & Cas. Ins. Co., 22 Fla. L. Weekly Supp. 948a (Miami-Dade County, Judge Rodolfo A. Ruiz, Jan. 21, 2015).

18. United Auto failed to provide such notice in this case, agreeing that it would pay eighty percent of all medically necessary expenses. United Auto did not provide clear and unambiguous notice of its election to utilize the permissive fee schedules as the basis for calculating and limiting reimbursements.

19. Accordingly, United Auto improperly applied the deductible to M&M’s charges, after reducing those charges by the permissive fee schedule percentages that it had not elected to utilize, and M&M is entitled to a partial summary judgment as to United Auto’s having misapplied the $1,000 Policy deductible.