Tag Archives: PIP insurers

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)

Two Favorable PIP Rulings for Mercury Insurance

Medicare Part B and other statutory fee schedules were permitted as a basis for reimbursement in the recent case Timothy M. Kehrig, DC, P.A. v. Mercury Insurance Company of Florida, heard by a Palm Beach County court.

The plaintiff filed suit charging that Mercury did not pay 80% of the amount billed for medical services. Rather, the defendant determined payment by calculating 80% of 200% of the charges allowed in the Medicare Part B fee schedule.

The question in dispute was whether Mercury could pay benefits in accordance with the fee contained in Fla. Stat. §627.736(5)(a)(2) (2008) and the policy.

The court ruled that Mercury could limit payment in accordance with statutory fee schedules.

Separately, a Pinellas County court recently permitted Mercury to limit payment by using statutory fee schedules in the PIP dispute Orthopedic Specialists v. Mercury Insurance Company of Florida.

The case related to a 2011 injury in which Mercury reimbursed the medical services provider at a rate of 80% of 200% of the benefits available under Medicare Part B.

“Medical benefits” were defined in the policy as meaning “eighty (80%) percent of all reasonable expenses allowed by the No-Fault Law, subject to the applicable fee schedules and payment limitations, for medically necessary …”

The court cited Geico General Ins. Co. v. Virtual Imaging Services, Inc., stating that the description of medical benefits payment “is not inconsistent with application of the fee schedules and limitations.”

Case Documents

Click on the link to read the Final Judgment for Defendant in the matter Timothy M. Kehrig, DC, P.A. v. Mercury Insurance Company of Florida, (Case No. 50-2011-SC-008363).

Click on the link to read the Final Summary Judgment in the matter Orthopedic Specialists v. Mercury Insurance Company of Florida, (Case No. 13-000073-SC).

Both cases involved a “U85 (05/2010)” endorsement to the policy.

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Filed under Case Law, Fla. Stat. 627.736 (2008), The Statutory "Fee Schedules"

Motion for Summary Judgment Granted in Two Pinellas PIP Cases

The Pinellas County Court ruled in favor of Direct General Insurance in two recent PIP cases heard in the Small Claims Division.

In both cases, the plaintiff alleged breach of contract for failure to pay 80% of reasonable and necessary medical expenses. Direct General responded with a Motion for Summary Judgment, claiming that it paid the medical expenses in accordance with the policy language.

The policy in question stipulated that the insurer will pay 80% of qualifying expenses. The court noted the presence of additional policy language that clearly stated the potential for further reductions in reimbursement, as follows:

“… in determining whether charges for medical expenses under this Part are reasonable, we may reduce payments for amounts that are billed to any lesser amount that results from the application of any schedule of charges or alternative reimbursement method that is expressly reference or authorized for use by the insurers under the No Fault Law.”

The court determined that Fla. Statute §627.736(5)(a)2 is the governing clause, even if it may not have been specifically referenced. The court cited Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So. 3d 63, 68 (Fla. 4th DCA 2011) in its decision.

The cases are Wood Health, Inc. vs. Direct General Insurance (Ref. 12-4904SC-SPC), and Spinal Corrections Centers vs. Direct General Insurance (Ref. 12-49088SC-SPC). Click on the case titles to view the court documents.

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Filed under Case Law, Fla. Stat. 627.736 (2008), Fla. Stat. 627.736 (2012)

Insurance Information Institute Comments on PIP Premium Changes and Significance of the January 1, 2013 Effective Date of 2012 PIP Law Changes

Tampa Bay Fox 13 recently featured a segment regarding the effect of House Bill 119, the 2012 PIP law change, on PIP premium rates.  Lynne McChristian of the Insurance Information Institute, shed some light what appears to be a lack of a premium decrease.  McChristian indicates that the recent insurer reports are not indicative of what could likely be the case after January 1, 2013, when all of HB119’s changes take effect.

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Filed under Fla. Stat. 627.736 (2012), Insurance Fraud, Licensing, The Statutory "Fee Schedules"