26 Fla. L. Weekly Supp. 688a
Online Reference: FLWSUPP 2608BAPTInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy provision stating that charge submitted for amount less than 200% of allowable amount under Medicare Part B fee schedule shall be paid in amount of charge submitted does not vitiate application of coinsurance provision limiting payment to 80% of reimbursable amount
SPINE & EXTREMITY REHABILITATION CENTER, INC. a/a/o Kristela Jean Baptiste, Plaintiff(s), v. GEICO INDEMNITY COMPANY, Defendant(s). County Court, 19th Judicial Circuit in and for St. Lucie County. Case No. 562017SC001036AXXXHC. September 20, 2018. Edmond Alonzo, Judge. Counsel: Bruce Katzell, The Law Office of Jeffrey R. Hickman, West Palm Beach, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FORFINAL SUMMARY JUDGMENT AND DENYINGDEFENDANT’S MOTION TO AMEND ANSWERAND DENYING PLAINTIFF’S MOTION FORSUMMARY JUDGMENT REGARDING BILLED AMOUNT
THIS CAUSE having come on to be heard on September 14, 2018, on the parties’ cross motions, and the Court having reviewed the aforementioned motions, the relevant legal authority, having heard argument of counsel, and having been sufficiently advised in the premises, the Court finds as follows:
1. This case involves a dispute whether an insured is subject to the coinsurance provision of Florida Statute 627.736(1)(a) when the charge submitted by the insured’s provider is for an amount less than the amount allowed by the schedule of maximum charges as described in subparagraph 627.736(5)(a)5.
2. Subparagraph 627.736(5)(a)5. reads:
5. . . .If a provider submits a charge for an amount less than the amount allowed under subparagraph 1., the insurer may pay the amount of the charge submitted.
And the corresponding language in the subject policy reads:
A charge submitted by a provider, for an amount less than the amount allowed above, shall be paid in the amount of the charge submitted.
See GEICO’s Florida Policy Amendment FLPIP (01-13), Page 3 of 11.
3. Plaintiff contends that the policy substituted the word “may” to “shall” and that plain reading of the policy mandates that when a medical provider bills an amount less than the “amount allowed above”, Geico “shall” reimburse the medical provider at the “amount of the charge submitted” without taking any further reductions or copayment.
4. After reviewing both the language of the statute and the policy, the Defendant’s change of the statutory word “may” to “shall” in the policy represents nothing more than the insurer opting and letting their insured know that there is some certainty to this particular means by which they are going to adjust these bills. It does not vitiate the application of the coinsurance.
5. 200% of the allowable amount under the participating physicians fee schedule of Medicare Part B is the number against which the bill needs to be applied. However, neither the policy nor the statute stops, there.
6. The statutory language is clear and the policy language directs the insurer to apply the lesser billed amount to 200% of the allowable amount and then subject it to the coinsurance provision. The insurer did so correctly in this case.
7. Based the foregoing, it is hereby ORDERED AND ADJUDGED:
8. Defendant’s Motion to Amend Answer and Affirmative Defenses is DENIED and Defendant’s Motion for Final Summary Judgment regarding the Billed Amount issue is GRANTED.
9. Plaintiff’s Motion for Summary Judgment regarding the Billed Amount issue is DENIED.
10. Plaintiff shall take nothing from this action, and Defendant shall go hence without day.
11. The Court reserves jurisdiction to determine Defendant’s entitlement to and amount of attorney’s fees and costs.
