Florida District Court of Appeals Reviews Personal Injury Protection Payments to Providers

As a driver in Florida, you are required to carry auto insurance for your motor vehicle. This insurance policy must provide Personal Injury Protection (PIP) to the insured. These benefits are under Florida Statute 627.736, and they include payments for medical benefits that are considered reasonable expenses for medically necessary care, surgeries, x-rays, dental care, and rehabilitative services. The benefits can be up to $10,000, but they may be limited to $2,500 if the injured insured did not have an emergency medical condition. Injured drivers often depend on these benefits to help alleviate medical costs, and emergency medical facilities have come to rely on the availability of payments from insurance companies.

wheelchair-1576246-638x425The Second District Court of Appeals looked into PIP payments in All State Indemnity Co. v. Markley Chiropractice & Acupuncture (2D14-3818). In this case, the insurance company appealed judgments in favor of two medical groups that performed medical care on two separate injured drivers after their respective auto accidents. There was no question that the injuries suffered by each party were covered under PIP. All were deemed reasonable and medically necessary. Both injured drivers assigned their benefits to each medical service provider. The providers both received benefits from the insurance company, but not for the amounts requested.

The question before the appellate court revolved around the calculation of benefits that the insurance company was obliged to pay under state law. Fla. Stat. § 627.736 (1)(a) allows for 80 percent of the billed amounts of benefits. The providers billed $3,522 and $165, but they only received $2,628.44 and $57.74 instead of $2,817.60 and $132. The insurance company argued that they correctly calculated and paid amounts under the alternate fee-schedule provisions of Fla. Stat. § 627.736, found in (5)(a)(2)(f), which allows the insurer to limit the reimbursement of 80 percent by using a schedule of maximum charges, calculating a reduction of 200 percent of allowable amounts for all other medical services, supplies, and care that are a part of the physician’s Medicare Part B schedule.

The providers at trial and on appeal looked to a recent Florida Supreme Court case, Geico Gen. Ins. Co. v. Virtual Imaging Services, Inc., 141 So. 3rd 147 (Fla. 2013), and argued that the insurance company’s policy language was ambiguous and insufficient to allow the reimbursement limitation. The Supreme Court in Virtual Imaging provided methodologies for the insurer to determine a reasonable charge for medical services, which is based on a fact-dependent inquiry. The appellate court, however, looked at how the Supreme Court determined “reasonableness” by referring to the Medicare fee schedules.

The district court did not agree with the trial court’s reliance on Virtual Imaging, and it felt that the legislature’s inclusion of Medicare-based fees was not ambiguous. The court determined that the policy’s language of limiting payment to “any amounts payable” under the fee schedule-based limitations found in the statute was enough notice to the providers that a further reduction of the benefits paid, beyond the 80 percent, per the schedule, was possible. The district court reversed and remanded the trial court’s decision in favor of the providers, determining that the providers should receive less than 80 percent of what was billed, reduced by the scheduled fees.

When you’ve been injured in a car accident, you want to access all available benefits. The Florida auto accident attorneys at Donaldson & Weston are to help you with your case. For a free, confidential consultation, call our office at 772-266-5555 or 561-299-3999.

More Blog Posts:

Florida Appellate Court Reinstates Injured Automobile Passenger Award of Over $93,000, South Florida Injury Lawyer Blog, February 17, 2016

Florida’s First District Court of Appeal Allows Child’s Wrongful Death Suit to Continue, South Florida Injury Lawyer Blog, January 18, 2016