26 Fla. L. Weekly Supp. 690a
Online Reference: FLWSUPP 2608UBIDInsurance — 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 Tarshish Ubidia, Plaintiff(s), v. GOVERNMENT EMPLOYEES INSURANCE COMPANY, Defendant(s). County Court, 19th Judicial Circuit in and for St. Lucie County. Case No. 562017SC001026AXXXHC. 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 FORPARTIAL SUMMARY JUDGMENT AND DENYINGDEFENDANT’S MOTION TO AMEND ANSWER ANDPLAINTIFF’S MOTION FOR PARTIAL SUMMARYJUDGMENT REGARDING BILLED AMOUNT
THIS CAUSE having come 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. The parties agree that the GEICO policy language tracks the provisions of Fl. Stat. 627.736(5)(a), with one exception relevant to the case at bar. The last subparagraph of 627.736(5)(a)5., which 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.
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.”
2. Plaintiff contends that this change of words from the statute’s “may” to the policy’s “shall”, creates a stand-alone direction as to the determination of the amount of reimbursement to be made for the charge submitted, and therefore renders inapplicable the coinsurance provisions of the policy to bills that are less than the maximum allowable amounts. This Court disagrees.
3. 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 notice to the insured (and by extension, to the insured’s assignee, the Plaintiff herein) of the certainty to this particular means by which the insurance company will be adjusting bills that are less than the maximum allowable amounts. This statutorily permissible option to pay the lesser charge submitted is not intended to, nor does it serve to vitiate the application of the coinsurance provision that is contained in this same section.
4. The insurance policy tracks Fl. Stat. Section 627.736(5)(a)1, both of which apply a coinsurance provision of 80% to all of the reimbursements subject to the subparagraphs which follow.
5. Here, the GEICO policy provided proper notice of its intention to limit reimbursement to the schedule of payments allowed under this paragraph, and Fl. Stat. Section 627.736(5)(a) specifically permits (and the GEICO policy specifically adopts) limitation on such reimbursement to 80% of 200% of the allowable amount under the applicable physician’s fee schedule of Medicare part B.
6. 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 statute nor the policy stops there.
7. Both the statutory and policy provisions defining reimbursement must each be read in pari materia. To do otherwise would render the coinsurance provisions meaningless. As a consequence, once the reimbursable amount to be paid is determined, then the coinsurance provision is applied. This was correctly done by the insurer in this case.
IT IS THEREFORE ORDERED AND ADJUDGED THAT:
8. The Defendant’s Motion to Amend Answer and Affirmative Defenses is DENIED and Defendant’s Motion for Partial Summary Judgment on the billed amount issue be and the same is hereby GRANTED and the Plaintiff’s Motion for Partial Summary Judgment on the billed amount issue be and the same is hereby DENIED.
9. IT IS HEREBY FURTHER ADJUDGED that the Court retains jurisdiction for the purpose of determining any motion by Defendant to tax fees and costs on this billed amount issue, and to determine any motion by Plaintiff to tax fees and costs or to enforce their partial judgment previously entered regarding the two percent issue . This partial judgment shall have no effect on the partial judgment previously entered regarding the two percent issue in this case.
