8 Fla. L. Weekly Supp. 802a
Insurance — Plaintiff/insured was not party to contractual agreement between medical provider and insurer and was not third-party beneficiary of contract — Agreement between provider and insurer was not a preferred provider agreement, but simply a negotiated fee schedule to be used if an insured of the defendant uses the provider’s services — Insurer entitled to summary judgment on issue of whether agreement entered into by provider is valid agreement — Ruling does not decide ramifications if provider is making demands on plaintiff for payment in excess of the contract rate
GLENDA AUTREY, Plaintiff, vs. HARTFORD INSURANCE COMPANY OF THE MIDWEST, Defendant. County Court, 19th Judicial Circuit in and for Indian River County. Case No. 2000-0724 CC 10. July 16, 2001. Joe Wild, Judge. Counsel: Joseph Shaughnessy. Norman Monroe.
SUMMARY JUDGMENT ORDER
The plaintiff and defendant have both filed motions for summary judgment dealing with the issue of a contract between the defendant and Dr. Clark, the plaintiff’s medical provider. The facts of the case pertinent to the issue in question are set out in Plaintiff’s Response to Defendant’s Motion for Summary Judgment; Plaintiff’s Motion for Summary Judgment and Memorandum of Law in Support of Plaintiff’s Motion for Summary Judgment.
The Court grants the Defendant’s Motion for Summary Judgment and denies the Plaintiff’s Motion for Summary Judgment. The reasons are as follows:
(1) The plaintiff is not a party to the contractual agreement between Dr. Clark and Community Care Network (CCN), nor is the plaintiff a legal third-party beneficiary of the contract.1
(2) The agreement between Dr. Clark and CCN is not a preferred provider agreement contemplated by Section 627.736(10), Florida Statutes. The agreement is a negotiated fee schedule to be used if an insured of the defendent uses Dr. Clark’s services. This is no different than an insurance company negotiating a fee to pay after the service has been rendered. The goal is to reduce the money disbursed by the insurance company and preserve the benefits available to the insured. The fact that the negotiations are done beforehand, as opposed to after-the-fact should not render the agreement void. The insured is not required to use any particular provider, and is not penalized by using a provider that is not one in the position of Dr. Clark. The fact that the plaintiff chose to use Dr. Clark was a fortuitous choice that worked to her benefit.
(3) The statutory scheme in Section 627.736(10), Florida Statutes, provides a means for an insurance company to give an insured the option of buying a PPO policy. This Court agrees with other court decisions which assert that the only way to provide a PPO policy in Florida is to follow the requirements of that section. However, the statute certainly doesn’t dictate what providers must charge for medical services and what insurers must pay for medical services. The section does allow the insurance company the flexibility to offer reduced premiums and altered coverages to insureds in return for their use of a preferred provider. In this case, however, the defendant did not intend to restrict the plaintiff in her choice of providers, and agreed to cover her in the manner indicated in the policy, which complied with Florida law. The facts are undisputed that the plaintiff chose her provider and the defendant paid benefits at a rate agreed to by Dr. Clark.
(4) This ruling applies only to the issue of whether the agreement entered into by Dr. Clark is a valid agreement. This ruling does not decide the ramifications if Dr. Clark is making demands on the plaintiff for payment in excess of the contract rate.
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1The plaintiff does, however, benefit from the contract to the extent that the plaintiff’s insurance benefits are dissipated at a reduced rate based on the contract between CCN and Dr. Clark.
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