28 Fla. L. Weekly Supp. 87b
Online Reference: FLWSUPP 2801DIREInsurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Gratuitous payments — Where PIP insurer paid claim to another medical provider in excess of what was required by policy and PIP statute, payment was gratuitous payment that did not exhaust PIP benefits — Insurer owes payment for plaintiff provider’s claim
FLORIDA SPINE & JOINT INSTITUTE LLC, Plaintiff, v. DIRECT GENERAL INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COSO19005536, Division 60. February 3, 2020. Michael Davis, Judge. Counsel: Vincent Rutigliano, Rosenberg & Rosenberg, P.A., Hollywood, for Plaintiff. Tamar Hoo-Pagan, for Defendant.
ORDER ON PLAINTIFF’S MOTIONFOR PARTIAL SUMMARY JUDGMENT
This cause having come before the Court on Plaintiff’s Motion for Partial Summary Judgment, the Court having heard argument of the parties, and being otherwise advised in the premises it is hereby ORDERED AND ADJUDGED, as follows:
That Plaintiff’s Motion for Partial Summary Judgment is hereby Granted. The Court finds that the service (99213) provided by the Plaintiff on December 28, 2019 was related and necessary; that reasonableness is not an issue as the at-issue policy adopts the fee schedule and therefore the at-issue service should be paid based upon 80% of 200% of the applicable Medicare rate; and that the bill for said service was timely received. These findings were based upon the affidavits filed by the Plaintiff. The Defendant did not dispute the foregoing during the hearing. The Defendant, additionally, confirmed during the hearing that the instant bill had not been paid.
Having found that the Plaintiff established a prima facie case the Court turns to the Defendant’s remaining affirmative defense that benefits are exhausted. The Defendant claims to have made benefit payments totaling $10,526.91. The Defendant claims to have made $526.91 in benefit payments above that called for by the policy.
The Court finds that the Defendant has not exhausted the $10,000.00 in policy benefits in the payment of valid claims. The Court finds that the Defendant made a payment to another provider that was in excess of that called for by the instant policy and Florida Law. When the deductible was properly applied and the proper percentage of the billed amount by West Boca Medical Center was allowed the Court found that the Defendant paid West Boca Medical Center $674.51 in excess of the amount the at-issue policy and Florida Law required the Defendant to pay. The Court finds that this excess payment was not provided for by the policy and Florida Law, was not a valid payment under the policy and Florida Law and constituted a gratuitous payment that cannot be counted against the available benefits. See Coral Imaging v. Geico, 955 So.2d 11 where the Court held that making a payment not provided for in the statute and policy cannot be counted against the available PIP benefits — “the provision [of 627.736] must be read as prohibiting Geico from paying the untimely and improperly-billed charges . . . as violative of the provisions of 627.736(5)(b).” See also Santiago v. Orr Indus., Inc., 407 So. 2d 1026, 1029 (Fla. 1st DCA 1981) (“An overpayment of compensation is presumed to be a gratuity unless there is a specific finding that some other reasonable basis exists for the overpayment.”). See also Northwoods Sports Medicine v. State Farm, 137 So.3d 1049 (Fla. 4th DCA 2014) [39 Fla. L. Weekly D491a] where the Court held that exhaustion only exists with the payment of valid claims — “once the PIP benefits are exhausted through the payment of valid claims, an insurer has no further liability. . .” See also Ocean Harbor Casualty Insurance Company v. Medical Specialists of Tampa Bay, 26 Fla. L. Weekly Supp. 534a (Fla. 6th Cir. Ct. App. 2013) holding “anything Ocean Harbor paid over the amounts calculated under the safe harbor provisions was voluntary or gratuitous and, to the extent that they exceeded the safe harbor provisions, Ocean Harbor should not be given credit for them.”
After subtracting $674.51 from the amount the Defendant claimed had been paid, $10,526.91, the Court finds that there are still benefits remaining of $147.60 ($10,526.91 – $674.51). The unpaid code, 99213, under the instant policy should be paid at 80% of 200% of the applicable Medicare rate of $76.61. The Court finds that the Defendant owes the Plaintiff $122.58.
