25 Fla. L. Weekly Supp. 297a
Online Reference: FLWSUPP 2503ARMAInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Clear and unambiguous election by insurer — Where PIP policy states that in no event will insurer pay more than 80% of No-Fault Act schedule of maximum charges, and policy was approved by Office of Insurance Regulation, insurer has clearly and unambiguously elected to limit reimbursement to permissive statutory fee schedules
ORTHOPAEDIC AND SPINE MEDICAL GROUP, INC., a/a/o Ramonita Armaiz, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 15-014065 COWE (83). March 21, 2017. Ellen Feld, Judge.
ORDER ON DEFENDANT’S MOTION FOR PARTIALSUMMARY JUDGMENT REGARDING APPLICATIONOF FEE SCHEDULE AND REASONABLENESS OFCHARGES
THIS CAUSE came before the Court on February 17, 2017, on Defendant, State Farm Mutual Automobile Insurance Company (hereinafter “STATE FARM”)’s, Motion for Partial Summary Judgment on the issue of whether STATE FARM may limit reimburse for medical services covered by PIP insurance to eighty percent (80%) of the “schedule of maximum charges” and the Court having heard argument of counsel and having reviewed the evidence of record, states as follows:
ORDERED AND ADJUDGES that Defendant’s Motion for Summary Judgment is GRANTED. Prior to July 2012, if an insurance carrier desired to limit PIP reimbursement to the schedule of maximum charges, it was required to follow the dictates of Geico Gen. Ins v. Virtual Imaging Services, Inc., 141 So.3d 147 (Fla. 2013) [38 Fla. L. Weekly S517a], because the PIP statute did not contain any directives as to how a carrier was to adopt the fee schedule limitation that was first placed into the statutory scheme in 2008. However, in 2012 the Florida Legislature amended the PIP statute to include express directives as to how a carrier can adopt the fee schedule limitations. This case is governed by this newer provision (Fla. Stat. 627.736(5)(a)(5)) which provides:
Effective July 1, 2012, an insurer may limit payment as authorized by this paragraph only if the insurance policy includes a notice at the time of issuance or renewal that the insurer may limit payment pursuant to the schedule of charges specified in this paragraph. A policy form approved by the office satisfies this requirement.
It is undisputed State Farm complied with these requirements. The Declarations Page of the policy renewal State Farm provided its insured contained, in relevant part, the following “Important Notice:”
The most we will pay for such reasonable medical expenses is 80% of the “schedule of maximum charges” found in the Florida Motor Vehicle No-Fault Law and the Limits section of the Florida Car Policy’s No-Fault Coverage.
Additionally, it is undisputed that State Farm’s policy form 9810A was approved by the OIR. The 9810A Policy explicitly states that State Farm may limit reimbursement based upon the application of the schedule of maximum charges. The “Limits” section of the policy provides, in relevant part:
. . .in no event will we pay more than 80% of the following No-Fault Act “schedule of maximum charges” . . .
(Policy Form 9810A at 14-16)
Based upon the renewal notice provision and the unambiguous limitation found in the policy, State Farm has both complied with the statutory requirements and advised the insured, in no uncertain terms, that it will reimburse for reasonable medical expenses, but in no event will it pay more than 80% of the fee schedule.1 Under the PIP statute as amended in 2012, a carrier is obligated to pay 80% of reasonable medical expenses, but it may limit reimbursement to the schedule of maximum charges if it complies with Fla. Stat. 627.736(5)(a)(5). The Court finds State Farm’s notice to limit reimbursement to the schedule of maximum charges to be clear and unambiguous. There is no disputed issue of material fact that State Farm complied with this requirement.
STATE FARM’s Motion for Partial Summary Judgment is granted. This case shall go forward todetermine the applicability of the Medicare coding policies and procedures as it pertain to CPT code A4556 for date of service March 24, 2014.
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1This Court also agrees with the Florida Supreme Court’s directions not to apply the Virtual imaging analysis to this case because the Supreme Court itself stated that the Virtual Imaging approach was not to be applied to policies issued after July 2012 as courts were to follow the new fee schedule limitations procedures found in Fla. Stat. 627.736(5)(a)(5). Id. at 141 So.3d 147.
