Third District Court of Appeals Issues Conflicting Decision Regarding Florida Personal Injury Protection Reimbursement to Medical Care Providers

A series of consolidated appeals in Florida Wellness & Rehabilitation v. Allstate Fire & Casualty Co. (Nos. 3D15-151; 3D14-2688; 3D14-3008; 3D15-149 & 3D15-150) asked whether or not the language in an insurance policy provided notice to the insured that payments would be issued according to Florida Statutes 627.736 (5)(a)(2)(f), which pays medical care providers at a rate of 80% of 200% of the Medicare Part B schedules. Five medical providers, as assignees of an injured party, filed suit against the insurance company, arguing that the policy did not provide a clear and unambiguous election to the insureds that the statutory schedules were to be used by the insurance company to limit reimbursement to providers. Summary judgment motions were filed by both sides, but the trial court ruled in favor of the insurance company, ultimately determining that the policy language offered a clear and unambiguous election to its insured. Medical Care The providers appealed, but the decision was ultimately affirmed with a certification that it is in conflict with the law in Florida’s Fourth District and a note that it is in line with recent rulings from the First and Second District Courts of Appeals.

The appellate court in this case first looked at the statute that allows insurers to limit reimbursement. The court pointed out that while the option is available to pay 80% of 200% of the allowable amounts listed under the Medicare Part B schedule, this option is permissive rather than required. The Florida Supreme Court previously held in GEICO v. Virtual Imaging Servs., Inc., 141 So. 3d 147, (Fla. 2013), that the insured must be put on notice that the limitations on payment are being elected by the insurance carrier. In Virtual Imaging, the Supreme Court deemed the payment of “reasonable expenses . . . for medically necessary . . . services” was mandatory, but the ability to use the Medicare fee schedules to limit reimbursements was not. Since the reimbursement was permissive, notice to the insured of the election then became necessary. The insurance company in that case did not indicate in any way that it planned to limit its reimbursements based on the law, which established the notice requirement.

The Third District disagreed with the Fourth District’s assertion that there was an ambiguity in the language of the policy, particularly the phrase “subject to.” Looking at Florida case law on other matters, the Fourth District appellate court pointed to several examples in which “subject to” indicates subordination when there’s a hierarchical effect on overlapping provisions within the Florida statutes. The court felt that any other interpretation of the policy would be counter-intuitive to the understood meaning of a phrase frequently used in Florida’s statutes. The lower court’s decision was affirmed.

If you’ve been in a car accident, you will want to utilize all the coverage provided by your insurance policy to cover all related expenses for medical care. The experienced South Florida car accident attorneys at Donaldson & Weston know how to navigate through insurance policies to maximize the damages available to you. We can help you with your personal injury claim, so call our office today at 772-266-5555 or 561-299-3999.

More Blog Posts:

Florida District Appellate Decision Allows Woman Injured by Slip and Fall to Pursue Negligence Action Against County, South Florida Injury Lawyer Blog, April 19, 2016

Florida District Court of Appeal Reviews Grocery Store Slip-and-Fall Case, South Florida Injury Lawyer Blog, March 9, 2016