9 Fla. L. Weekly Supp. 867c
Insurance — Personal injury protection — Preferred provider rates — Insurer may not reduce fees payable to medical provider because provider entered into contract with PPO organization to accept reduced rates payable under PPO policy where medical provider is assignee of insured, and insured did not have a PPO policy — Question certified: May an insurance company reduce fees payable to a doctor for medical care because the treating physician entered into a contract with a PPO organization to accept the reduced fees payable under a PPO policy, even though the patient treated did not have a PPO policy and the physician took an assignment of the insured’s rights under the policy in return for treatment?
DR. WILLIAM B. WATERS (Christina Miller), Plaintiff, vs. NATIONWIDE MUTUAL INSURANCE COMPANY, Defendant. County Court, 14th Judicial Circuit in and for Bay County. Case No. 01-CC-1087. December 28, 2001. John D. O’Brien, Judge. Counsel: Andrew D. Wyman, Marks & Fleischer P.A., Ft. Lauderdale, for Plaintiff. Jay M. Walker, St. Petersburg, for Defendant.
SUMMARY JUDGMENT
The facts in this case are not in dispute. The parties entered into a stipulation of fact and further affirmed during the hearing that the facts are settled. It is only the application of the law to the facts that the parties debate.
The Defendant insurance company issued a insurance policy to Christine Miller. The policy was not a PPO policy as authorized by Fla. Stat. 627.736. Thereafter Christine Miller was injured in an auto accident, assigned her rights under the policy to the Plaintiff, and received medical treatment from the Plaintiff. Plaintiff now complains because the insurance company refused to pay more than PPO rates even though the policy was not a PPO policy.
The Defendant asserts the right to pay reduced rates because Plaintiff entered into a contract with Beech Street Corporation, a Preferred Provider Organization, as did the Defendant. Even though the contract was not admitted in this proceeding, the Defendant asserts that based on the Beech Street Contract it is entitled to establish the amount to be paid in accord with the fee schedules of that contract. The Defendant, in effect, asserts the right to pay PPO rates, not because it issued a PPO policy, but because the provider entered into a contract with a PPO Organization.
This argument must fail. Plaintiff has the right to bring this action only because of the assignment of the insured’s rights. Those rights are not diminished by any contract which the Plaintiff doctor may have with Beech Street or any other third party. To the contrary, those rights are fixed by the terms of the Defendant’s policy and the applicable law.
The insurance company here seeks to have the best of both worlds. It did not issue a PPO policy which would have paid lower premiums, but nevertheless it seeks the advantage of a PPO policy to pay lower medical rates. To accept this argument, the Court would have to accept the proposition that the right of the insurance company to pay reduced rates depends on the chance selection of the provider rather than compliance with Fla. Stat. 627.736. According to this argument, if the selected doctor would ever accept PPO rates, evidenced by his contract with a PPO organization, then he must always accept such dates if the insured’s carrier is also a signatory. This Court cannot accept such a proposal.
The motion of the Plaintiff for Summary Judgment is hereby granted. The Court specifically reserves jurisdiction to award costs, interest and attorney fees.
The parties have requested this Court certify the question presented in this case as one of great public importance under Fla. R. App. P. 9.030. The parties say there are hundreds of cases with this same issue pending in various courts around the state. Therefore, since this same issue has arisen in many cases and since there is no controlling precedent, this Court hereby certifies the following question:
May an insurance company reduce fees payable to a doctor for medical care because the treating physician entered into a contract with a PPO organization to accept the reduced fees payable under a PPO policy, even though the patient treated did not have a PPO policy and the physician took an assignment of the insured’s rights under the policy in return for treatment?
* * *
