Tag Archives: PIP insurance

FL PIP Guide Readers: Vote Now for the 100 Best Legal Blawgs

Readers of the FL PIP Guide are invited to show their support for the blog by voting in the ABA Journal’s annual competition for the 100 Best Legal Blawgs.

Please nominate Roig Lawyers’ FL PIP Guide blog by clicking here to provide a brief explanation on why you like the blog!

In addition to your name and affiliation, you will be asked to provide the URL to the FL PIP Guide (www.flpipguide.com).

You also have the chance to identify a specific blog post that you consider to be representative of the quality of coverage provided by the FL PIP Guide.

Click on the link below to get started.
http://www.abajournal.com/blawgs/blawg100_submit/

Friend-of-the-blawg briefs are due no later than 5 p.m. ET on Friday, August 8, 2014.

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Filed under Uncategorized

Defendant’s Motion to Dismiss Granted with Prejudice in PIP Benefits Case Involving Challenge to “Emergency Medical Condition” (EMC) Provision

In a second ruling within one week involving Florida’s amended PIP law, the U.S. District Court for the Southern District of Florida dismissed a case challenging reimbursement under the amended statute’s “emergency medical condition” or “EMC” provision. See our earlier post titled Court Grants Defendant’s Motion to Dismiss in Robbins v. Garrison P & C.

Sendy Enivert sued her auto insurance company, Progressive Select, alleging breach of contract for failing to pay her PIP benefits to a limit of $10,000. Enivert’s claim involved the newly added provision to Florida’s PIP law which limits PIP benefits depending on whether a claimant has suffered an emergency medical condition.

Plaintiff Enivert interpreted this language to mean that an insured is limited to $2,500 only if a medical provider determines that there is no emergency medical condition. She argued that because, in her case, no medical provider ever made such a determination, she was entitled to the full $10,000. In other words, because no medical provider determined that she did not have an emergency medical condition, she was entitled to full benefits.

Defendant Progressive read the statute to mean the opposite, i.e., that a medical provider must affirmatively determine that an emergency medical condition does exist in order for the insured to be eligible for reimbursement of the full amount.

The court agreed with Progressive, concluding that the PIP statute clearly indicates that a determination that a claimant has suffered an emergency medical condition is required in order to receive benefits in excess of the $2,500 limit. Since a medical provider did not determine that Enivert had an emergency medical condition, she was not entitled to the full $10,000 in benefits.

The court also looked to the legislative intent behind the PIP statute. It concluded that the clear legislative intent was to decrease PIP fraud by placing more stringent requirements in order to receive the maximum amount of benefits.

Based on the above, the court granted Progressive’s motion to dismiss Enivert’s case.

The case is Sendy Enivert v. Progressive Select Insurance Co., Civil Action No. 14-CV-80279-Ryskamp/Hopkins (S.D. Fla. July 23, 2014). Click on the link to read the court ruling.

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Filed under Case Law, Fla. Stat. 627.736 (2012)

State Farm Granted Summary Judgment in Lake Worth Chiropractic PIP Benefits Case

On July 14, 2014, the 15th Judicial Circuit for Palm Beach County affirmed a lower court decision granting summary judgment to State Farm in a claim for PIP benefits brought by Lake Worth Emergency Chiropractic Center.

In the underlying case, Judge Bosso-Pardo granted defendant’s Motion for Final Summary Judgment, entering final judgment for the defendant, State Farm, upon finding that the pre-suit demand letter, required by Florida Statute 627.736(10) (2010), was insufficient in that it demanded payment for services that were never billed to State Farm.

Judge Bosso-Pardo found that the Plaintiff’s “withdrawing” the unbilled service after suit had commenced was insufficient to cure the defect and that the demand letter requirements under Florida Statute 627.736(10) must be strictly construed and adhered to by those seeking to initiate litigation against a Florida PIP insurer.

The Circuit Court affirmed this decision, concluding that section 627.736(10) requires strict compliance and that, in this case, the demand letter did not strictly comply with the PIP statute requirements. As such, Lake Worth Emergency Chiropractic Center failed to satisfy the condition precedent to filing its law suit, and the trial court was correct in awarding final summary judgment in favor of State Farm.

The case is Lake Worth Emergency Chiropractic Center v. State Farm, in the Fifteenth Judicial Court for Palm Beach County, Case No. 502012AP000034XXXXMB. Click on the link to read the court opinion.

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

More Than Half of Florida PIP Claimants Hire an Attorney

PIP claimants are increasingly being represented by legal counsel, according to a new study released by the Insurance Research Council (“IRC”) titled Attorney Involvement in Auto Injury Claims.

In 2012, the study notes that 36 percent of auto injury PIP claimants nationwide were represented by attorneys, compared to 31 percent in 2007. For bodily injury claims, representation rose slightly to 50 percent.

Compared to claimants without legal representation, PIP claimants with attorneys were found to have a greater likelihood of the following behavior:

  • Sought more treatment in a pain clinic, including MRIs
  • Experienced longer waiting times for claim payments
  • Collected lower net payments
  • Involved in alleged fraudulent claims

Historical trends from 1977 to the present are outlined in the IRC chart below.

Attorney_Involvement_Fig 1_cr

Attorney involvement was also measured by state. Florida ranked at the top of the list, with more than 50% of claimants represented. Kansas, where 12% of PIP claimants are represented, was the lowest ranking state.

Data is drawn from 12 participating insurers and 35,000 auto injury claims closed with payment under the five principal passenger coverage areas, according to survey sponsors.

Click on the link to read more about the Attorney Involvement in Auto Injury Claims study.

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Filed under Fla. Stat. 627.736 (2008)

4th District Court of Appeal Denies Rehearing in PIP Benefit Dispute

The Fourth District Court of Appeal has denied motions for rehearing by appellants in a PIP case decided in the insurer’s favor. The case was the consolidation of two separate PIP cases.

Insureds in both cases sought treatment for injuries sustained in separate accidents and assigned their PIP benefits to their treatment providers. One of the insurers, State Farm, reduced the amount paid to Northwood Sports Medicine, and Northwoods subsequently sued. Prior to that filing, the insured’s PIP benefits were exhausted. State Farm moved for summary judgment; Northwoods amended its complaint to allege that State Farm reduced payments in bad faith. The trial court granted the motion for summary judgment on the sole ground of exhaustion of benefits.

Likewise, in the second case, the insured assigned his benefits to Wellness Associates of Florida. USAA Insurance Co. reduced the payments to Wellness, and Wellness filed a complaint for damages. At the time the suit was filed, less than $14 in unpaid PIP benefits remained and, while the lawsuit was pending, PIP benefits were exhausted. USAA moved for summary judgment, Wellness amended its complaint to allege bad faith, and the trial court entered summary judgment based upon exhaustion of benefits.

For jurisdictional reasons, the appellate court transferred the Northwoods case to the circuit court. The question that the appellate court answered in the affirmative in the Wellness case is whether post-suit exhaustion of benefits absolves the insurer from responsibility to pay an otherwise valid claim where the exhaustion occurred after the insurer: (1) paid an amount that the provider claims is less than required by the contract; (2) received a pre-suit demand letter notifying the insurer of the medical provider’s dispute; and (3) was served with the filed complaint.

In its rationale, the court extended its decision in Simon v. Progressive, rejecting the “reserve or hold” theory by which an insurer is to put money in reserve if it denies or reduces a claim until that claim is resolved. The court concluded that “where the reasonableness of the provider’s claim is in dispute, post-suit exhaustion of benefits extinguishes the provider’s right to further payments, as long as exhaustion is prior to the establishment of the amount to which the medical provider is entitled to under PIP.” The court concluded that post-suit exhaustion of benefits—as was the case in Wellness—should be treated no differently than pre-suit exhaustion of benefits, as long as the amount of PIP benefits to which the provider is entitled has not been established. The court therefore affirmed the final judgment of the trial court in Wellness.

The case in the District Court of Appeal of The State of Florida Fourth District, January Term 2014, is Northwoods Sports Medicine and Physical Rehabilitation, Inc., (A/A/O Suzanne Cabrera), and Wellness Associates of Florida, Inc., (A/A/O Daniel North), Appellants, v. State Farm Mutual Automobile Insurance Company and USAA Casualty Insurance Company, Appellees, Nos. 4d11-1556 and 4d11-3796, [March 5, 2014]. Click on the link to read the June 4, 2014 ruling in the case.

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

Wal-Mart Adds Car Insurance to its List of Services

Wal-Mart is branching out into auto insurance.

The nation’s largest retailer has teamed with AutoInsurance.com to offer a free price comparison service that lets its customers quickly find and choose car insurance policies online and in real time in order to lower their costs.

While Wal-Mart is not selling car insurance, shoppers can log on to AutoInsurance.com or access the site through Wal-Mart’s website at http://www.walmart.com/autoinsurance.

According to a story on Claims Journal, the site will retrieve customers’ current auto insurance policy information to those who log on and provide their name, address, date of birth and contact information. AutoInsurance.com can then automatically complete the required coverage information for a side-by-side comparison. Within minutes, the service provides multiple quotes from some leading insurance companies including Esurance, Safeco and Progressive, the article reported.

Customers can then opt to buy the policy online right away, speak with a licensed agent at 800-700-7500, or save their information and purchase a policy later.

The service is currently up and running in eight states: Arkansas, Louisiana, Mississippi, Missouri, Oklahoma, Pennsylvania, Tennessee and Texas, and will be rolled out nationwide in the next few months. Wal-Mart shoppers will see in-store displays promoting the service.

In a recent media briefing, Daniel Eckert, senior vice president of services for Wal-Mart U.S., said that the company will be AutoInsurance.com’s exclusive retail partner and collect promotion payments in its role as marketer. In turn, AutoInsurance earns a commission every time a policy is sold.

AutoInsurance.com is a division of Fort Lee, N.J.-based Tranzutary Insurance Solutions LLC, a licensed property and casualty insurance agency that was created after Wal-Mart saw an opportunity to improve this market. Wal-Mart noted that car insurance is among the biggest monthly expenses of its customers, sometimes even topping health care costs for some of them.

Joshua Kazam, founder of AutoInsurance.com and the founder and chairman of Tranzutary, surveyed people and found that 90 percent comparison price shop for online for products and services like airline tickets, but only one in five do so for auto insurance because the process is so complicated.

Together, they’ve created a quicker service where shoppers can buy and save on car insurance and where shoppers receive their final price—no bait and switch tactics.

Before deciding on its current program, Wal-Mart tried out several pilot programs with Tranzutary, including one frontrunner where customers in Pennsylvania, who purchased policies from AutoInsurance.com, saw annual savings of $1,168, on average, Claims Journal reported.

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Filed under Fla. Stat. 627.736 (2008)

Cost of Florida PIP Premiums Start to Drop Due to HB 119 Reforms

Almost two years after the Florida legislature passed House Bill 119, drivers may now start to notice a slight drop in this year’s automobile insurance rates resulting from reforms that helped lower Personal Injury Protection (PIP) premiums.

Although the primary goal of PIP, also known as no-fault insurance, was to reduce court cases and payment delays for injured drivers, the number of PIP claims and PIP payments escalated, even though the number of auto accidents did not increase over the past few years.

According to an article in the April 21 edition of Highlands Today, a local edition of the Tampa Tribune, PIP premiums are roughly 2 percent of Florida’s collected insurance premiums, but questionable claims make up nearly 50 percent of fraud referrals. The Division of Insurance Fraud received over 3,000 PIP fraud complaints in 2005-06, and obtained 225 convictions in 2007, the article added.

However, as we reported on this blog on March 31, a recent National Insurance Crime Bureau (NICB) report shows that tighter legislation, enhanced public awareness, and coordinated law enforcement is having a positive effect on PIP fraud in Florida.

In calculating cost reductions to the consumer, most insurers used rates from a Pinnacle study which projected legislative reforms would save Florida policyholders roughly 14-24 percent. Typically, 25 percent of a consumer’s total auto insurance premium cost comes from PIP.

A preliminary DOI analysis of the rates submitted by the top 20 automobile insurance companies writing PIP insurance, encompassing more than 75 percent of the Florida market, showed a 13.2 percent decrease. Therefore, a statewide reduction in PIP averaging 13.2 percent would translate to a 3-4 percent savings for the policyholder, the DOI figures.

DOI’s analysis was compiled to demonstrate the cumulative effect of House Bill 119 after the first required rate filing due in October 2012 and the second rate filing on Jan. 1, 2014, the Highlands Today story said.

However, rate changes are still pending for 2014, according to Amy Bogner, Deputy Director of Communications at the Florida Office of Insurance Regulation. “The anticipated cumulative effect of these two rate filings in the legislation was a 25 percent overall decrease in PIP rates,” Bogner explained.

Auto insurers who did not decrease PIP premiums by the cumulative 25 percent were required to demonstrate why the company’s savings should vary.

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Filed under Fla. Stat. 627.736 (2012), Insurance Fraud

Florida Supreme Court Refuses to Review PIP Case

The Florida Supreme Court has refused to consider a petition seeking to overturn a 2012 state law reducing PIP benefits.

In an attempt to curb fraud and lower insurance rates, HB 119—Personal Injury Protection (PIP) for Auto Insurance Fraud—requires people involved in motor vehicle crashes to seek treatment within 14 days, and allows up to $10,000 in benefits for emergency medical conditions and up to $2,500 for non-emergency conditions.

The law also prevents accident victims from using PIP coverage to pay for treatment by certain medical providers, and set benchmarks for insurers to lower rates on PIP coverage.

In 2013, Leon County Circuit Judge Terry Lewis ruled that the law illegally shut out some medical providers, namely acupuncturists and massage therapists.

As reported in an earlier blog post titled “Motion for Rehearing of Florida PIP Injunction is Denied,” the Florida First District Court of Appeal reversed the ruling in October, 2013, saying that the challengers to the law needed a “factual” plaintiff who had actually been harmed by the law rather than a hypothetical plaintiff, as named in the complaint. The Florida Supreme Court denied review of that decision in this week’s ruling.

An attorney representing medical providers who claim they were unfairly shut out by the law said he anticipates filing an amended case within 30 days using a named plaintiff alleged to have been harmed by the 2012 PIP reforms.

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Filed under Case Law, Fla. Stat. 627.736 (2012), Insurance Fraud

Roig Lawyers Partner, Jeff Tutan, Speaks at 2014 Medical Claims Defense Network on Topic of Use of Mobile X-rays

On April 16, 2014, Roig Lawyers Partner, and Board Certified Trial Attorney, Jeff Tutan presented at the Medical Claims Defense Network Conference in Orlando, Florida.  Jeff Tutan, head of the firm’s trial practice group, discussed his recent success at jury trial in a case involving a medical provider’s claim for reimbursement for “mobile x-ray” services.  During the round table presentation, Attorney Tutan discussed how he, partner Jessica Martin, and senior associate attorney Jenna Hackman, successfully defended such a case involving these increasingly prevalent medical services.

For more information, contact attorney Jeff Tutan at jtutan@roiglawyers.com.

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Filed under Fla. Stat. 627.736 (2008), Fla. Stat. 627.736 (2012), Licensing

Questionable PIP Claims Decline in Florida, Reports NICB

Tighter legislation, enhanced public awareness, and coordinated law enforcement efforts appear to be having a positive effect on PIP fraud in Florida, according to a recent report by the National Insurance Crime Bureau (NICB).

The new study published by the organization showed Florida’s personal injury protection (PIP) questionable claims (QCs) have dropped 7.6 percent from 2012 to 2013. More striking, however, was the extraordinary decline from 2010 through 2013, when Florida’s staged accident QCs decreased 61.82 percent during that time period.

Compare those statistics to 2009, when Florida not only topped the nation in PIP QCs reported to the NICB, but also had twice as many as the second-highest state, New York. From 2008 through 2010, the total number of QCs in Florida increased by 34 percent.

When NICB delved further into these results, it found that about 62 percent of total PIP costs and about 43 percent of PIP treatment costs came from soft tissue treatments. Massage treatments accounted for 22 percent of those treatments, and massage therapists had the largest increase in charges per patient at 51 percent from 2005 through 2010, after factoring in for medical inflation.

“We are encouraged by the decline in questionable claims that we’ve seen recently, but by no means are we declaring victory in Florida,” said NICB President and CEO Joe Wehrle.  “Florida remains a hotbed for fraudulent activity and we can’t afford to ease up for a moment in our fight against those who would abuse the system and burden Florida consumers.”

In September 2011, the Hillsborough County Commission was one of the first legislative bodies to enact a county ordinance to license PIP clinics and deter suspicious vehicle collisions in the county. Although an injunction against the law remains in effect, it hasn’t stopped other legislation. In February 2012, Miami-Dade County passed a similar ordinance requiring registration of PIP clinics, and the Florida legislature passed House Bill 119 in May 2012.

This two-part legislation institutes stronger penalties for medical providers who commit PIP fraud, including a five-year license suspension and a ten-year restriction from PIP reimbursement. It also imposes a 14-day post-accident window for accident victims to seek medical treatment and reduces specified PIP benefits and treatments. A lawsuit and injunction ensued, but eventually, the law was put into effect in late October 2013.

Although NICB does not receive all QC data in Florida, the data used to produce this report came from the same sources used in previous Florida QC reports. “Combining these legislative and regulatory efforts with a robust public awareness campaign and aggressive law enforcement response, the modest improvement in 2013 PIP QC data does suggest the initial stages of a positive downward trend,” NICB confirmed.

Click on the link to read the NICB Data Analytics ForeCAST Report regarding Florida Personal Injury Protection (PIP).

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