Category Archives: Fla. Stat. 627.736 (2008)

The 11th Judicial Circuit Court Issues Key Ruling in Health Care Clinic Licensure Case

On March 10, 2015, the Eleventh Judicial Circuit in and for Miami-Dade County issued a ruling in favor of Imperial Fire & Casualty Insurance in a mandatory licensing (House Bill 119) case. The Court found that the charges submitted for Personal Injury Protection (PIP) benefits to Imperial Fire & Casualty, to be unlawful and thus, noncompensable pursuant to Florida’s Motor Vehicle No-Fault Law.

Imperial Fire & Casualty issued a policy of automobile insurance to the Insured under which the Defendant, Magic Hands Solutions Inc. sought payment. Magic Hands Solutions operated as a medical clinic and allegedly rendered medical treatment to the Insured who was injured in an automobile accident. Subsequently, Magic Hands Solutions submitted charges for payment of PIP benefits to Imperial Fire & Casualty. Magic Hands Solutions was advised that the claim submitted for PIP benefits was not payable because the clinic was not properly licensed pursuant to Section 627.736, Florida Statutes (2013).

In 2012, the Legislature required mandatory licensing for all clinics holding an exempt status, whether by issuance of Certificate of Exemption or self-determined, in order for clinics to receive reimbursement pursuant to the “PIP Statute.” Hence, a clinic must be licensed under Part X, Chapter 400 to receive reimbursement for PIP benefits, unless it qualifies for an exception listed in Section 627.736(5)(h).

The Court found that the Magic Hands Solutions being wholly owned by a license massage therapist does not qualify for any of the exceptions delineated in §627.736(5)(h)(1)-(6) and was required to obtain a Health Care Clinic license as a condition precedent to receiving reimbursement of PIP benefits.

As a result of Magic Hands Solutions’ failure to obtain a Health Care Clinic License, the Court found that the charges submitted were unlawful and thus, noncompensable pursuant to Florida’s Motor Vehicle No-Fault Law and that Imperial Fire & Casualty.

Imperial Fire & Casualty Insurance Company vs. Magic Hands Solution Inc., Case No. 2014-2211 CC 24 (01) (Fla. 11th Circuit March 10, 2015).

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Filed under Fla. Stat. 627.736 (2008)

CFO Jeff Atwater Supports Fighting Fraud During 2015 Legislative Session

CFO Jeff Atwater supports the Health Care Clinic Proposed Legislation House Bill 1127 and Senate Bill 1306 that strengthen the Agency for Health Care Administration’s (“AHCA”) Health Care Clinic Act (“HCCA”). The proposed legislation:

  • Creates new certificate of exemption mandates for clinics exempted from mandatory licensure in HB 119 and criminal penalties for certain AHCA clinic violations;
  • Increases the number of crimes that may be investigated by the Division of Insurance Fraud;
  • Requires insurers to have SIU departments with specific requirements and establishes state oversight to help fight insurance fraud;
  • Creates additional criminal penalties for unlawful claims, whether paid or not.

Please click here to review the full summary.

For additional information you may visit http://www.flhouse.gov.

If you have any questions concerning this topic, please contact any member of the Roig Lawyers Insurance Services Group.

Contributing Authors:

MICHAEL A. ROSENBERG

MARK J. ROSE

MIGUEL R. ROURA

DENNIS LAROSA

 

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Filed under Fla. Stat. 627.736 (2008)

Appellate Court Rules that Two Providers Not “Prevailing Insureds”

A trial court ruling awarding attorney’s fees to two medical treatment providers was reversed by the Appellate Division of the Eleventh Judicial Circuit in and for Miami-Dade County in an opinion filed January 9, 2015. The court concluded that the providers did not constitute “prevailing insureds” and therefore were not entitled to the statutory award of attorney’s fees.

Fritznel Leconte was allegedly injured in an automobile accident on July 22, 2006, while insured by a PIP insurance policy issued by United Automobile Insurance Co. He received treatment from two providers—A Rehab Associates and Med Plus Centers—and assigned his PIP claims to them. The cases were tried separately and consolidated on appeal.

In response to a pre-suit statutory Demand Letter, United determined it was responsible only for the cost of the pre-IME (Independent Medical Exam) treatments and offered A Rehab $595.20 and Med Plus $1,324.80. At trial, verdicts were returned in favor of the providers for the exact amounts offered earlier by United.

The providers filed motions for attorney’s fees as “prevailing insureds” pursuant to Florida Statutes section 627.428. That statute grants an insured the right to recover attorney’s fees when the insured obtains a judgment or decree against the insurer, i.e., is a “prevailing insured.” The question before the court was whether an insured is a “prevailing insured” when it obtains a judgment no better than the amount offered by the insurer pre-suit.

The court held that the “prevailing insured” referred to in the statute is “one who has obtained a judgment greater than any offer of settlement tendered by the insurer.” Put another way, “insureds who rejects settlement offers that would make them whole cannot seek attorney’s fees under section 627.428.”

In this case, the judgments received were not greater than the amount offered by the insurer prior to the suit, so the insureds do not qualify as “prevailing insureds” and are not entitled to attorney’s fees pursuant to section 627.428.

United Automobile Ins. Co. v. A Rehab Assoc. and United Automobile Ins. Co. v. Med Plus Centers, Case Nos. 12-413 AP, 13-148 AP, 12-381 AP, 13-147 AP (Fla. 11th Cir. January 9, 2015).

Click on the link to access the court ruling.

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Filed under Case Law, Fla. Stat. 627.736 (2008)

Florida Needs 35 More Judges, Says Florida Supreme Court

The texting while driving law that took effect in October, 2013 is one of several reasons why the Florida judicial system needs 32 additional county court judges and three new circuit court judges, according to an annual Certification of Need for Additional Judges published December 22 by the Florida Supreme Court.

The recent news that Florida has surpassed New York to become the third largest state in the nation, while not cited by the Court, coincides with increasing pressure on the state’s judicial system.

The Florida Supreme Court analysis breaks down judicial needs by county, with the greatest number of county court certified judicial position recommendations as follows:

  • Three judges in the Fourth Circuit of Duval County (Jacksonville area)
  • Eight judges in the Eleventh Circuit of Miami-Dade County
  • Eight judges in the Thirteenth Circuit of Hillsborough County (Tampa area)
  • Five judges in the Fifteenth Circuit of Palm Beach County

A total of three circuit court judges are also suggested. One circuit court certified judicial position is requested for the First Judicial Circuit, which serves Escambia, Santa Rosa, Okaloosa, and Walton counties in northwest Florida. This circuit experiences a heavy criminal workload and a steady number of tobacco cases, according to the court analysis.

Two circuit court judicial positions are recommended for the Fifth Judicial Circuit, which encompasses Citrus, Hernando, Lake, Marion, and Sumter Counties. The Fifth circuit is the ninth most populous circuit with 5.5% of Florida’s population, according to the court.

There is no request for new judges in the District Courts of Appeal at this time

In its analysis, the Court cites recent trends in the volume and type of cases:

  • Six percent increase in probate filings
  • Nine percent increase in dependency filings
  • One percent increase in circuit civil filings (excluding real property)

The Court also reported declines in domestic relations filings (three percent), felony and juvenile delinquency filings (seven percent each).

The Florida Supreme Court request notes that judges across the state continue to bear the burden of increasing workloads after the number of support staff – including case managers, law clerks and magistrates – was reduced in earlier budget cut backs.

Click on the link to read the full annual Certification of Need for Additional Judges published December 22 by the Florida Supreme Court.

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Filed under Case Law, Fla. Stat. 627.736 (2008)

Staged Accident Recruiter from Palm Beach County Sentenced to Nine Years

A West Palm Beach man, who participated in an $8 million insurance fraud scam, was recently sentenced to nine years in prison for his role in the matter.

Joel Antonio Simon Ramirez, about whom we reported on our FL PIP Guide in April, helped recruit individuals to participate in staged automobile crashes. According to a story in the Palm Beach Post, the 30-year old worked together with three other chiropractors who filed fake insurance claims for the participants in these crashes. They operated the scheme out of clinics throughout Palm Beach County.

Following a six-week trial in April, all four defendants were found guilty of money laundering and mail fraud. Ramirez was also found guilty of helping stage the auto accidents.

By violating PIP insurance provisions, these schemes not only cost insurers but also hurt Florida drivers, federal prosecutors said. The conspiracy was part of a larger staged accident ring dubbed “Operation Sledgehammer” by investigators who discovered that many participants damaged vehicles using sledgehammers to give the appearance of a crash.

Nearly 60 people have been charged in federal court and almost 40 have been charged in state court as part of this sweeping investigation. Most have pleaded guilty to participating in staged accidents and then seeking treatment for bogus injuries. According to prosecutors, the five ringleaders fled to Cuba.

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud

Third DCA Rules for Insurer in GEICO v. Gables Insurance Recovery

In an opinion issued December 10, 2014 in the case of GEICO v. Gables Insurance Recovery (a/a/o Rita M. Lauzan), the Third District Court of Appeal quashed a Circuit Court Appellate Division’s decision affirming final judgment in favor of Gables Insurance.

Lauzan, who was insured by GEICO, was injured in an automobile accident in 2008. After obtaining medical treatment, she assigned her GEICO policy benefits to All X-Ray Diagnostic Services, which subsequently assigned the benefits to Gables Insurance.

GEICO paid less than the amount it had been billed, and Gables Insurance filed a breach of contract action against GEICO. GEICO argued that Lauzan’s $10,000 PIP benefits had been exhausted and that it therefore had no further liability to Gables.

Deciding in GEICO’s favor, the Third District Court of Appeal held that the PIP statute does not require an insurer to pay more than the $10,000 limit in PIP coverage. Further, it does not require an insurer to “set aside” funds in anticipation of litigation. The Court noted that two other District Courts of Appeal have addressed the issue, holding that a showing of bad faith or impropriety on the part of the insurer is required before it can be held liable for benefits above the statutory limit.

Quoting a recent Fourth District Court of Appeal case, Northwoods v. State Farm, the Court concluded that once PIP benefits are exhausted, “an insurer has no further liability on unresolved, pending claims, absent bad faith in the handling of the claim by the insurance company.”

The case is GEICO Indemnity Co. v. Gables Insurance Recovery (a/a/o Rita M. Lauzan), Case No. 3D13-2264 (Fla. 3rd DCA, December 10, 2014). Click on the link to read the court opinion.

The case cited is Northwoods Sports Medicine v. State Farm, 137 So. 3d 1049 (Fla. 4th DCA 2014).

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Filed under Case Law, Fla. Stat. 627.736 (2008)

Third DCA Upholds Ruling in PIP Case Millennium Radiology v. State Farm

On December 10, 2014, the Third District Court of Appeal affirmed a trial court ruling in Millennium Radiology (a/a/o Yesenia Arango) v. State Farm. In the case, Yesenia Arango’s $10,000 PIP policy limits were exhausted after a lawsuit was filed and served on State Farm by Millennium Radiology.

Roig Lawyers attorney Mark Rose had successfully argued in the lower court that paying out the entire $10,000 was a complete bar to additional claims against the policy of insurance, absent bad faith on the insurer’s part or the insurer’s payment of untimely submitted bills. Following the ruling, the case was certified as a question of great public importance to the Third District Court of Appeal.

The Third District Court of Appeal affirmed the ruling, finding that in an action brought by an assignor of PIP benefits that is founded upon a breach of contract, exhaustion of PIP benefits after a lawsuit is filed “absolves the insurer from any responsibility to pay an otherwise valid claim” where the exhaustion occurred (1) after the insurer paid an amount less than the provider feels was appropriate; (2) after a lawsuit has been served on the insurer; and (3) absent any bad faith by the insurer in the handling of the claims.

The case is Millennium Radiology v. State Farm, Case No. 3D12-3143 (Fla. 3rd DCA, December 10, 2014). Click on the link to view the court ruling.

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Filed under Case Law, Fla. Stat. 627.736 (2008)