Volume 23

23 Fla. L. Weekly Supp. 524c

Online Reference: FLWSUPP 2306HORIInsurance — Personal injury protection — Coverage — Emergency services — Exhaustion of policy limits — Despite statutory mandate that insurer reserve $5,000 for emergency service providers, insurer was not required to reserve funds for emergency service provider’s claim reduced through erroneous application of statutory fee schedule and, absent showing of bad faith, is not liable for balance of reduced claim after exhaustion of benefits

23 Fla. L. Weekly Supp. 513a

Online Reference: FLWSUPP 2306LOCKInsurance — Personal injury protection — Coverage — Medical expenses — Emergency services — Exhaustion of policy limits — Insurer was required to hold in reserve beyond 30 days that portion of a emergency provider’s claim that was disputed and remained unpaid at end of 30-day reserve period — Exhaustion of benefits is not defense to payment of disputed portion of emergency provider’s claim

23 Fla. L. Weekly Supp. 302b

Online Reference: FLWSUPP 2304MAUGInsurance — Personal injury protection — Coverage — Medical benefits — Emergency services — Exhaustion of benefits — PIP insurer was primary payor for emergency services provider’s claim where provider filed substantially completed claim form within 30-day period during which insurer was required to reserve funds for payment of claims by providers of emergency services or care — Fact that secondary insurer paid claim did not relieve PIP insurer of its obligation to pay — Provider’s motion for summary judgment granted

23 Fla. L. Weekly Supp. 490b

Online Reference: FLWSUPP 2305SKYLInsurance — Personal injury protection — Coverage — Emergency medical condition — Where qualified medical provider had not determined prior to filing of suit that insured suffered emergency medical condition, insurer did not breach PIP policy by limiting benefits to $2,500 — Post-suit determination of emergency medical condition does not create disputed issue of material fact preventing entry of summary judgment

23 Fla. L. Weekly Supp. 482a

Online Reference: FLWSUPP 2305BLAIInsurance — Personal injury protection — Coverage — Emergency medical condition — Under amendments to PIP statute requiring PIP insurer to pay benefits up to $10,000 if qualified medical provider has determined that claimant had emergency medical condition and limiting reimbursement to $2,500 if qualified provider has determined that claimant did not have emergency medical condition, insurer properly limited benefits to $2,500 where qualified provider has not determined that insured suffered emergency medical condition — Motion to stay case pending resolution of cases pending before district court of appeal concerning issue of when benefits above $2,500 become available when there has been determination of emergency medical condition is denied where facts in appealed cases are different from facts in instant case, and stay would result in inordinate delay — Motion to abate case pending resolution of appealed cases is denied — Abatement is not appropriate when cases do not involve same parties

23 Fla. L. Weekly Supp. 372a

Online Reference: FLWSUPP 2304HENRInsurance — Personal injury protection — Coverage — Emergency medical condition — Under provisions of PIP statute requiring PIP insurer to pay benefits up to $10,000 if qualified medical provider has determined that claimant had emergency medical condition and limiting reimbursement to $2,500 if qualified provider has determined that claimant did not have emergency medical condition, insurer properly limited benefits to $2,500 where qualified provider had not determined that insured suffered emergency medical condition

23 Fla. L. Weekly Supp. 247a

Online Reference: FLWSUPP 2303STEVInsurance — Personal injury protection — Coverage — Medical expenses — Emergency medical condition — Unless medical provider, as expressly defined by statute, makes affirmative determination that injured party had emergency medical condition, benefits are limited to $2500 — No merit to plaintiff’s argument that insurer was required to pay out full $10,000 in PIP benefits unless a medical provider expressly stated or determined that claimant did not have an emergency medical condition

23 Fla. L. Weekly Supp. 565a

Online Reference: FLWSUPP 2306MOYAInsurance — Personal injury protection — Coverage — Medical expenses — Where PIP policy includes endorsement that states that insurer will pay 80% of reasonable expenses as well as endorsement that limits reimbursement to permissive statutory fee schedule, policy does not clearly and unambiguously elect to apply fee schedule — No merit to insurer’s argument that Office of Insurance Regulation’s approval of policy form satisfies requirement for notice of intent to apply statutory fee schedule and eliminates any need for analysis of ambiguity and clarity of policy — Fraud — Insured’s deposition testimony does not establish that medical provider or insured knowingly perpetrated fraud and does not create direct conflict with supervising physician’s opinions as to relatedness and medical necessity of services rendered — Where supervising physician’s affidavit is sufficient to establish reasonableness of charges, and insurer did not present any evidence to contradict affidavit, summary judgment is entered in favor of provider

23 Fla. L. Weekly Supp. 762b

Online Reference: FLWSUPP 2307MACHInsurance — Personal injury protection — Coverage — Medical expenses — Examination under oath — Where PIP statute authorizes insurers to require submission to EUO as condition precedent to receipt of benefits, and PIP policy incorporated EUO provision of PIP statute by reference and specifically set forth EUO requirement, insured’s failure to attend EUOs on three separate occasions bars recovery of benefits by insured or medical provider/assignee

23 Fla. L. Weekly Supp. 617a

Online Reference: FLWSUPP 2306GALDInsurance — Personal injury protection — Requests for documentation of relatedness and necessity of MRI that were made more than 30 days after insurer’s receipt of MRI bill are untimely — MRI provider was not required to supply requested documentation that was not in its possession or inform insurer that it did not possess documents — Total forfeiture of PIP benefits is not remedy for failure to provide documentation; insurer’s remedy in face of refusal to provide documentation is to petition court for entry of order permitting discovery