26 Fla. L. Weekly Supp. 595a
Online Reference: FLWSUPP 2607BTInsurance — Personal injury protection — Coverage — Exhaustion of policy limits — Emergency medical condition — Where insurer properly denied medical provider’s claim in excess of $2,500 in absence of determination that insured had suffered emergency medical condition and then made payment of additional PIP benefits up to $10,000 policy limit to hospital that was first provider to submit emergency medical condition determination, payment to hospital did not constitute bad faith handling of claims — Summary judgment is entered in favor of insurer on issue of exhaustion of benefits
B.T., an insured individual by and through his/her assignee, PETER J. DORAN, D.C., P.A., Plaintiff, v. GARRISON PROPERTY & CASUALTY INSURANCE COMPANY, a Foreign corporation, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 16-CC-026873. Division I. September 13, 2018. Joelle Ann Ober, Judge. Counsel: Philip Friedman, for Plaintiff. Jesse Groves, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FORSUMMARY JUDGMENT ON THE ISSUE OFEXHAUSTION OF BENEFITS andFINAL SUMMARY JUDGMENT FOR DEFENDANT
THIS CAUSE came before the Court at a hearing on June 26, 2018, on Defendant’s Motion for Summary Judgment on the Issue of Exhaustion of Benefits filed November 10, 2016 (“Motion”). Having reviewed and considered Defendant’s Motion, the arguments presented by the parties, the applicable law, and being otherwise fully advised, the Court finds:
1. On August 16, 2016, Plaintiff instituted this action for personal injury protection (PIP) benefits against the Defendant. This matter involves a motor vehicle accident that allegedly occurred on February 16, 2016 for which the insured assignee had a policy of insurance with the Defendant. The following timeline was established through the deposition testimony of the Defendant’s corporate representative and was not controverted by any record evidence.
a. On March 2, 2016, Defendant received its first claim pertaining to the underlying accident from National Radiology Consultants. On March 12, 2016, Defendant applied the deductible to that claim and paid 80% of the remaining balance without applying fee schedule limitations.
b. On March 3, 2016, Defendant received a claim from Oak Hill Hospital (hereinafter “hospital”) in the amount of $37,137.50. The initial submission by the hospital included a claim form, but no other records.
c. On March 10, 2016, Defendant received a claim from ER Physicians. The claim was submitted electronically and was unaccompanied by medical records. On March 14, 2016, Defendant paid the ER Physicians claim at 80% of the billed amount.
d. On March 31, 2016, Defendant received a claim from Plaintiff.
e. On April 1, 2016, Defendant adjusted the claim from the hospital and issued an explanation of reimbursement (“EOR”) which indicated denial of the charges on grounds that $2,500 had already been paid and that no Emergency Medical Condition (“EMC”) determination had been received. This initial denial of the hospital claim was done in error because at that time benefits in the amount of $2,500 had not yet been paid; however, the error has no bearing on the matters at issue in this Plaintiff’s Complaint. The EOR issued to the hospital requested submission of an EMC determination.
f. On April 3, 2016, Defendant partially paid the Plaintiff’s claim up to the $2,500 limit and denied the remaining amount on the grounds that $2,500 had been paid and no EMC determination had been received. The EOR issued to Plaintiff also requested submission of an EMC determination.
g. On April 8, 2016, the hospital responded to Defendant’s request for an EMC determination and submitted its medical records for the claim it had previously submitted. Those records included an EMC determination.
h. On April 14, 2016, the hospital claim was adjusted and paid the remaining $7,500 in PIP benefits, thereby exhausting the full $10,000 in PIP benefits available under the policy as a result of the EMC determination.
i. The hospital was the first PIP claimant to submit an EMC determination, and, as of the date of benefit exhaustion, was the only claimant to have responded to Defendant’s request and submit an EMC determination.
j. Plaintiff did not respond to Defendant’s request for an EMC determination.
2. “Once the PIP benefits are exhausted through the payment of valid claims, an insurer has no further liability on unresolved, pending claims, absent bad faith in the handling of the claim by the insurance company.” Northwoods Sports Medicine and Physical Rehabilitation, Inc. v. State Farm Mutual Insurance Company, 137 So. 3d 1049, 1057 (Fla. 4th DCA 2014) [39 Fla. L. Weekly D491a]; see Progressive American Insurance Company v. Stand-Up MRI of Orlando, 990 So. 2d 3, 4 (Fla. 5th DCA 2008) [33 Fla. L. Weekly D1746a].
3. Binding precedent in this Circuit establishes that submission of an EMC determination is a necessary element of valid notice of a covered loss beyond $2,500. See Enterprise Leasing Company v. AFO Imaging, Inc., 24 Fla. L. Weekly Supp. 487a (Fla. 13th Cir. Ct. (appellate) Oct. 24, 2016).
4. Defendant has submitted record evidence that policy limit for PIP benefits in this matter was $10,000 and that $10,000 has been paid in PIP benefits; thereby exhausting the available benefits under the policy.
5. Plaintiff’s argument relative to the adjustment of the claims being done in a discriminatory fashion against Plaintiff are speculative and not supported by record evidence.
6. The Court finds that Plaintiff has failed to provide or point to competent summary judgment evidence to indicate that there exists a genuine issue of material fact as to the existence of bad faith in the handling, adjustment, and payment of the claims in this matter so as to preclude summary judgment.
7. Additionally, the legal authority relied upon by the Plaintiff to support its argument that the Defendant’s actions in this matter constitute bad faith are distinguishable. Unlike the circumstances in Coral Imaging Services v. GEICO Indemnity Insurance Company, 955 So. 2d 11 (Fla. 3d DCA 2006) [31 Fla. L. Weekly D2478a], there is no record evidence indicating that Defendant paid untimely, or otherwise invalid, claims to exhaust the available PIP benefits while denying a timely and valid claim of another provider.
8. Here, Defendant properly denied Plaintiff’s claim in excess of $2,500 in the absence of an EMC determination. Defendant then made payment in excess of $2,500, up to exhaustion of the $10,000 in benefits, to the first provider to submit an EMC determination with supporting medical records. Existing legal authority does not support that Defendant’s actions in this matter, in particular prioritizing and paying the claims of the first provider to provide an EMC determination and a valid notice of a claim in excess of $2,500, constitute bad faith.
9. The Defendant paid the total amount of PIP benefits available to the insured, or the insured’s assignees, under the policy. The Defendant fully performed its obligations relative to the payment of PIP benefits under the policy and gained nothing through the manner in which it adjusted and paid the claims.
Based on the foregoing, it is therefore ORDERED AND ADJUDGED
1. Defendant’s Motion for Summary Judgment on the Issue of Exhaustion of Benefits filed November 10, 2016 is hereby GRANTED.
2. Final Summary Judgment is hereby entered in favor of Defendant, GARRISON PROPERTY & CASUALTY INSURANCE COMPANY. Plaintiff shall take nothing by this action and Defendant shall go hence without day.
