25 Fla. L. Weekly Supp. 840b
Online Reference: FLWSUPP 2509LAUEInsurance — 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
PRECISION DIAGNOSTIC, INC., a/a/o MARCELA LAUER, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court in and for St. Lucie County. Case No. 562016SC001806C2XXXX. November 3, 2017. Edmond H. Alonzo, Judge. Counsel: Theophilos Poulopoulos, Schiller, Kessler & Gomez, PLC, Fort Lauderdale, for Plaintiff. Melissa G. McDavitt, Conroy Simberg, West Palm Beach, for Defendant.ORDER ON CROSS MOTIONS FOR SUMMARY JUDGMENT
THIS CAUSE having come before the Court on October 12, 2017 upon Defendant’s Motion for Summary Judgment and Plaintiff’s Cross-Motion for Final Summary Judgment on the issue of whether State Farm’s policy elected to limit its reimbursement to the schedule of maximum charges found at Fla. Stat. § 627.736(5)(a)1, the Court having reviewed the motions and submitted authority, having heard the argument of counsel, and after being otherwise fully advised in the premises, it finds:
The accident giving rise to this cause of action took place on April 29, 2015. At the time of the accident, Defendant covered the assignor under a policy of automobile insurance providing $10,000 in No-Fault Benefits. The policy of insurance included a declarations page and policy form 9810A. Following the accident, Plaintiff provided to the assignor medical care. Plaintiff submitted to Defendant bills for medical expenses Plaintiff alleges were medically necessary and related to the automobile accident. Defendant limited reimbursement of the medical expenses to no more than 80% of the No-Fault Act’s schedule of maximum charges. Plaintiff alleges that Defendant did not properly elect in its policy, and therefore did not properly provide the assignor notice of its intent to use, the No-Fault Act’s schedule of maximum charges. Defendant asserts that its policy properly elects the use of the fee schedule to limit reimbursement of reasonable medical expenses and complies with the statutory notice requirement.
The No-Fault Act’s (Fla. Stat. § 627.736(1)(a)) requires automobile insurance policies issued in Florida to provide No-Fault Benefits coverage for “reasonable” medical expenses. “[T]he PIP Statute sets for a basic coverage mandate: every PIP Insurer is required to — that is, the insurer ‘shall’ — reimburse 80% of reasonable expenses for medically necessary services.” Geico General Insurance Co. v. Virtual Imaging Services, Inc., 141 So. 3d 147, 155 (Fla. 2013) [38 Fla. L. Weekly S517a]. This provision is the heard of the PIP statute’s coverage requirements. Id.
In 2012, the Florida Legislature amended the PIP statute to include express directives as to how a carrier can adopt the Schedule of Maximum Charges to limit reimbursement of reasonable medical expenses. See Fla. Stat. § 627.736(5)(a)5. This case is governed by this provision, which provides as follows:
Effective July 1, 2012, and 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. . .
The question for this court is, therefore, whether State Farm’s insurance policy includes a notice that State Farm a limit payment of reimbursement to no more than the schedule of charges.
The policy at issue in this case consists of a declaration page and the 9810A policy form. The policy states as follows:
We will pay in accordance with the No-Fault Act properly billed and documented reasonable charges for bodily injury to an insured caused by an accident resulting from the ownership, maintenance, or use of a motor vehicle as follows:
1. Medical Expenses
We will pay 80% of properly billed and documented medical expenses, but only if that insured received initial services and care from a provider described in A. below within 14 days after the motor vehicle accident that caused bodily injury to that insured.
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The policy defines the term “medical expenses” to include “reasonable charges.” The term “reasonable charge” is also defined.
The No-Fault Coverage Portion of the policy includes a “Limits” section. The Limits section states as follow: “We will limit payment of Medical Expenses described in the Insuring Agreement of those policies 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’s ‘scheduled maximum charges’. . .” The Limits section then lists the referenced schedule of maximum charges.
The policy satisfies the PIP statute’s basic coverage mandate by providing coverage for 80% of reasonable medical expenses. The policy then clearly and unambiguously limits payment of such reasonable medical expenses to no more than 80% of the No-Fault Act’s schedule of maximum charges. The State Farm policy properly elects the use of the fee schedule to limit reimbursement of reasonable medical expenses pursuant to Florida Statute §627.736(5)(a)(1). State Farm complied with the statutory notice requirement of Florida Statute §627.736(5)(a)(5).
Plaintiff argues that State Farm policy is ambiguous because it includes a “reasonableness methodology” and a “fee schedule methodology.” Plaintiff argues that State Farm’s policy does not clearly elect one payment methodology to the exclusion of the other, and that State Farm has created a “hybrid” method. However, Plaintiff’s argument was expressly rejected by the Supreme Court of Florida in Allstate Insurance Company v. Orthopedic Specialist, etc., 42 Fla. L. Weekly S38a (Fla. Jan. 26, 2017), reh’g denied, SC15-2298, 2017 WL 1130950 (Fla. Mar. 27, 2017) .
Accordingly and as a matter of law, State Farm properly paid Plaintiff using the schedule of maximum charges limitation.
It is therefore:
ORDERED AND ADJUDGED that Defendant’s Motion for Summary Judgment is GRANTED and Plaintiff’s Cross-Motion for Final Summary Judgment is DENIED.
