27 Fla. L. Weekly Supp. 1053a
Online Reference: FLWSUPP 2712MCDOInsurance — Personal injury protection — Coverage — Deductible — Where medical provider’s bill fell within deductible, irrespective of whether insurer reduced bills by application of statutory fee schedule prior to applying resulting sum to deductible or applied total bill to deductible, provider was not damaged by insurer’s initial erroneous calculation of amount to be applied to deductible
SPECIALTY HEALTH ASSOCIATES LLC, a/a/o Tasha McDougald, Plaintiff, v. GEICO INDEMNITY COMPANY, Defendant. County Court, 19th Judicial Circuit in and for Martin County. Case No. 19000059SCAXMX. January 17, 2020. Jennifer Alcorta Waters, Judge. Counsel: Melissa Milford, Law Office of Jeffrey R. Hickman, West Palm Beach, for Defendant.
ORDER ON PLAINTIFF’S MOTION FORSUMMARY JUDGMENT AND DEFENDANT’SRENEWED MOTION FOR SUMMARY JUDGMENT
THIS CAUSE came before this Court on Defendant’s Renewed Motion for Summary Judgment on January 14, 2020, and this Court, having heard argument of Counsel, and having reviewed the file, hereby finds as follows:
1. Plaintiff filed this action on or about January 11, 2019.
2. According to the Complaint, on or about November 22, 2016, Tasha McDougald was involved in a motor vehicle accident in which she sustained injuries.
3. This is an action for personal injury protection benefits under an automobile insurance policy issued by the Defendant, for medical services rendered by Plaintiff to Tasha McDougald.
4. The policy provided for $10,000 in PIP benefits, which became available only after the $1,000.00 deductible was paid1.
5. Plaintiff rendered treatment services to Tasha McDougald commencing on November 29, 2016.
6. Plaintiff submitted a bill to Defendant, which, according to the Affidavit of Ashley Mobley, the PIP litigation adjustor for Defendant, was the first bill received2. The bill was for a total of $145.00
7. Defendant denied the claim as it was the first bill submitted, and the deductible was not met.
8. At the time that the claim was made, the Defendant calculated the reimbursable amount of the bills pursuant to 200% of the Medicare Part B Fee Schedule, which reduced the amount to $103.28, and applied the amount to the $1,000.00 deductible.3 Because the amount was less than the deductible, Defendant denied the claims.
9. After the Florida Supreme Court decided Progressive Select Ins. Co., v. Florida Hospital Medical Center, SC18-278 (Fla. December 28, 2018) [44 Fla. L. Weekly S59a], the Defendant reevaluated the denial of benefits in this case, and applied the deductible in accordance with the new precedent from the Supreme Court, under the authority of Ramon v. Aries Insurance Company, 769 So. 2d 1053 (Fla. 3d DCA 2000) [25 Fla. L. Weekly D1830a], which permits an insurer to correct an error in payment of bills.
10. After the re-evaluation of the denial of benefits, Defendant then applied the deductible to 100% of the Plaintiff’s bill, which totaled $145.00, also less than the $1,000.00 deductible amount.
11. Plaintiff’s bill was the first received and fell within the applicable $1,000.00 deductible, regardless of the deductible methodology applied by Defendant.
12. Therefore, Plaintiff was not entitled to Personal Injury Protection benefit reimbursement by Defendant. Defendant is not responsible to Plaintiff for amounts within the deductible.
13. “The functional purpose of a deductible, which is frequently referred to as self-insurance, is to alter the point at which an insurance company’s obligation to pay will ripen.” Int’l. Bankers Ins. Co. v. Arnone, 552 So. 2d 908, 911 (Fla. 1989). The insured is responsible for the payment of the deductible amount. Mercury Insurance Company of Florida v. Emergency Physicians of Central, 182 So.2d 661, 667 (Fla. 5th DCA 2015) [40 Fla. L. Weekly D2364a].
14. Because the amount in controversy was less than the deductible amount, payment of the balance was the responsibility of the insured.
15. Plaintiff submitted no actual evidence that it had been damaged. Plaintiff has failed to establish any damages as a result of conduct by Defendant. Regardless of whether the bills at issue were applied to the deductible before the fee schedule, reduction or after, the bills would have been applied to the deductible in their entirety.
IT IS THEREFORE ORDERED AND ADJUDGED AS FOLLOWS:
1. Defendant’s Renewed Motion for Summary Judgment is GRANTED.
2. Plaintiff’s Motion for Summary Judgment is DENIED.
3. Plaintiff, Specialty Health Associates, LLC (a/a/o Tasha McDougald) shall take nothing by this action, and Defendant, Geico Indemnity Company, shall go hence without delay.
4. This Court reserves jurisdiction to entertain any timely motions regarding an award of attorneys’ fees and costs.
5. The trial scheduled for March 30, 2020 is hereby removed from the docket.
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1There were no affidavits filed which opposed the fact that the deductible on the policy was $1,000.00. The complete policy was attached as Exhibit “A” to the Affidavit of Ashley Mobley and filed in support of Defendant’s Renewed Motion for Summary Judgment.
2There were no affidavits in opposition filed which opposed the fact that this was the first bill received by Defendant.
3Prior to the Florida Supreme Court decision in December of 2018, the 4th DCA’s controlling precedent in the 19th Circuit permitted the reduction of the bills, even those applied to the deductible. See State Farm Mutual Automobile Insurance Co. v. Care Wellness Center, LLC (Virginia Bardon-Diaz), 240 So. 3d 22 (Fla. 4th DCA 2018) [43 Fla. L. Weekly D573a]
