Tag Archives: PIP statute

Eleventh Circuit Dismisses PIP Case Involving EMC and Massage Therapy

A class action suit filed by plaintiff Accumed Chiropractic against Progressive Select Insurance was dismissed on July 31, 2014 by Circuit Court Judge Antonio Arzola. Judge Arzola concluded that the action was inappropriate for class action treatment.

The suit was brought on behalf of plaintiff itself and two putative classes. The first class was to be anyone who was denied payment by Progressive under PIP or MedPay insurance coverage where Progressive’s denial was based on an assertion that an Emergency Medical Condition for the insured was not established.

The second class was to be defined as anyone whose PIP or MedPay claim was denied because the health care service was for massage therapy or acupuncture. Plaintiff sought both declaratory relief and damages for breach of contract.

Plaintiff stipulated at the hearing that it did not have standing to sue for MedPay benefits. As for the PIP claims, Judge Arzola found that the “necessary and individualized questions associated with the underlying PIP claims of the class will predominate in this Action.” As a matter of law, therefore, plaintiff’s case could not proceed as a class action, and the complaint was dismissed without prejudice.

The case is Accumed Chiropractic & Wellness Center, Inc. v. Progressive Select Insurance Company, Case No. 13-CA-029396 (Fla. 11th Cir. Ct., July 31, 2014). Click on the link to view the court order.

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Filed under Case Law

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)

Court Grants Defendant’s Motion to Dismiss in Robbins v. Garrison P & C

On July 18, the U.S. District Court for the Southern District of Florida dismissed a case in which the plaintiff challenged reimbursement under the amended statute’s “emergency medical condition” (“EMC”) provision.

Glenaan Robbins sued her auto insurer, Garrison P&C Insurance Co., alleging that Garrison violated the 2013 provision of Florida’s PIP law that limits PIP benefits depending on a determination of whether or not the claimant suffered an emergency medical condition.

Robbins sustained injuries in an April 2013 car accident. She was treated for her injuries and alleged that ultimately “no determination was made that she did not have an emergency medical condition.” When Robbins submitted her claim to her insurer Garrison, Garrison limited her reimbursement to $2,500.

FL PIP law requires that an insurance company must reimburse its injured insured up to $10,000 if certain medical providers determine that the injured person had an emergency medical condition. Reimbursement is limited to $2,500 if a provider determines that the injured person did not have an emergency medical condition.

In this case, no determination was made either way that an emergency medical condition did or did not exist. Plaintiff Robbins argued that where there has been no such determination, insurance companies must reimburse medical expenses up to $10,000. In other words, unless a determination of no emergency medical condition is made, the plaintiff is entitled to the higher amount.

Reviewing the language of the statute and legislative intent, however, the court concluded that Robbins’ argument had no merit. Rather, where there has been no determination of an emergency medical condition made, PIP medical benefits are not to exceed $2,500. Thus, contrary to Robbins’ argument, the conclusion of the court was that unless there is a determination of an emergency condition, the reimbursement is limited to $2,500.

The court therefore held that Robbins had failed to allege a statutory claim and her case was dismissed.

The case is Glenaan Robbins v. Garrison Property & Casualty Insurance Co., Civil Action No. 13-81259-Civ-Scola (S.D. Fla. July 18, 2014). Click on the link to read the court ruling.

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

Motion for Rehearing of Florida PIP Injunction is Denied

On November 26, 2013, the First District Court of Appeals dismissed a motion for rehearing on its October ruling to reverse an injunction placed on reforms to Florida’s PIP system. The reforms, contained within HB 119 and signed into law by Gov. Rick Scott in 2012, ban PIP payments to acupuncturists and massage therapists. The reforms also require that claimants seek treatment from a physician or hospital within 14 days of an accident.

A group of acupuncturists, massage therapists, and chiropractors filed for an injunction, which was ultimately granted. The Court of Appeals ruled in October that the injunction should be reversed. It upheld this decision by denying a motion for rehearing on its ruling.

We wrote in September about reservations expressed by a three-judge panel from the 1st District Court of Appeals regarding the challenge made by acupuncturists, massage therapists and chiropractors to key parts of Florida’s 2012 landmark reform of the personal-injury protection (PIP) auto insurance law, in a blog post titled “Judges Question Challenges Brought to Florida’s No Fault Insurance Law.”

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

Judges Question Challenges Brought to Florida’s No Fault Insurance Law

A three-judge panel from the 1st District Court of Appeals expressed their reservations Tuesday about a challenge made by acupuncturists, massage therapists and chiropractors to key parts of Florida’s 2012 landmark reform of the personal-injury protection (PIP) auto insurance law, The News Service of Florida reports.

In the hearing, the three judges questioned how the modifications to the longstanding no-fault insurance system have diminished individual medical coverage or court access, as the Florida PIP Defense Fund and its representatives contend.

In the hearing, the three judges questioned the Florida PIP Defense Fund’s assertions that modifications to the longstanding no-fault insurance system have diminished individual medical coverage or court access.

The FL PIP Defense Fund named acupuncturist Robin Myers, chiropractor Gregory Zwirn and massage therapists Sherry Smith and Carrie Damaska as plaintiffs in the suit, as well as “Jane Doe,” which is being seen as a tactic by The Fund to qualify for standing in the case and represent individuals injured by motor-vehicle collisions.

According to Judge T. Kent Wetherell, this is not a real lawsuit, but a situation where an individual makes a claim against their own insurance company because many accidents conclude with no driver being found ‘at fault.’

The judges expressed a desire to expedite a ruling, but no timeline was given for a decision on the state’s request to overturn a temporary injunction that was imposed on certain parts of the law in March.

The 2012 reform law signed by Gov. Rick Scott requires those involved in motor vehicle crashes to seek treatment within 14 days, allows up to $10,000 in benefits for emergency medical conditions and $2,500 for non-emergency conditions. Scott and state Chief Financial Officer Jeff Atwater championed the 2012 reforms to reduce fraud in auto insurance, which they say costs motorists almost $1 billion a year through the increased costs of coverage.

The alternative is to replace the system with bodily-injury insurance, which could put more questions of medical coverage into the courts as injured parties seek to recoup expenses from at-fault motorists.

A bodily-injury insurance system is the most likely PIP alternative if further change is sought. This would push more medical coverage questions into the courts, since injured parties would seek to establish fault for expense reimbursement purposes.

If PIP is eliminated, Wetherell notes, challengers to the law would face a similar economic impact and future.

In March, Leon County Circuit Judge Terry Lewis sided with the challenge to sections of the law, criticizing it for depriving individuals of getting the medical care that they need.

Adam Levine, an attorney representing the FL PIP Defense Fund, praised Lewis for considering issues bigger than economic impacts, but Florida Solicitor General Allen Winsor said Lewis failed to determine that the law is unconstitutional.

The insurance industry has generally supported the changes to the law.

Reform efforts are being delayed as a result of the injunction, according to Donovan Brown, state government relations counsel for the Property Casualty Insurers Association of America.

“In order to address fraud and abuse within Florida’s no-fault auto insurance system and provide Floridians relief from being the number one state in the nation for questionable auto claims, it is imperative that consumers receive the benefit of the PIP reforms becoming fully effective,” Brown said in The News Service of Florida article.

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

PIP Legislative Calendar Governs EUO Requirements

Florida insurers are now being forced to navigate between sometimes conflicting rulings on Examinations Under Oath (“EUO”) based on pre- and post-2012 changes to the PIP/No-Fault laws.

Insurance companies and their defense law firms were disappointed when the Florida Supreme Court ruled in late June that GEICO could not withhold benefits to a policyholder in a pre-2012 auto case based on the policyholder’s unwillingness to attend an EUO.

In the matter Merly Nunez v. GEICO General Insurance Company, the Florida Supreme Court was asked by the U.S. Court of Appeals for the Eleventh Circuit to rule on, “[w]hether, under FLA. STAT. § 627.736, an insurer can require an insured to attend an [examination under oath] as a condition precedent to recovery of [personal injury protection] benefits?”

The Court’s answer was in the negative, in a split 5-2 vote. The majority ruled that, “[t]he Florida No-Fault statute is mandatory and does not recognize such a condition. It is therefore invalid and contrary to the statutory terms.”

“Swift and virtually automatic payment” is the primary intent of PIP laws, notes the majority. While GEICO argued the need for fraud prevention and claims investigations, the Court viewed these actions as contrary to a fast case resolution.

The majority opinion was written by Justice Perry, with Justices Pariente, Lewis, Quince, and Labarga concurring. Justice Canady wrote a dissenting opinion, in which Justice Polston concurred.

“Insurers have relied on the discretionary use of examinations under oath (EUOs) in appropriate cases to obtain relevant, needed information not only for the assessment of claimed losses, but for the prevention of fraud and abuse of the PIP system,” said Donovan Brown, Florida counsel and regional manager for the Property Casualty Insurers Association of America as quoted in an Insurance Journal article. “This ruling is another blow to Florida’s consumers in the fight against PIP fraud because the ruling further exposes consumers to the rampant PIP fraud that has plagued the Florida auto insurance system for far too long.”

Florida Governor Rick Scott approved changes to the state’s PIP statutes in May, 2012. As of January 1, 2013, insureds must now comply with all terms of a No-Fault policy, including any requirement to submit to an Examination Under Oath.

Click on the link to read the Supreme Court of Florida ruling in Merly Nunez v. GEICO General Insurance Company, No. SC12-650, dated June 27, 2013.

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Filed under Case Law, Examinations Under Oath (EUO), Fla. Stat. 627.736 (2008), Fla. Stat. 627.736 (2012), Insurance Fraud

Fort Myers Chiropractor Arrested, Caught Paying Confidential Informant to Fake Injuries

Fort Myers, FL chiropractor, Dr. David Greydinger, was arrested last week after investigators caught Greydinger submitting fraudulent insurance claims for non-existent auto accidents.  Reports indicate Greydinger, of MYO Health Clinic, paid informants kickbacks to submit claims totaling $6,000 arising out of non-existent accidents.  Reports indicate that MYO Health Clinic remains open for business at this time.

Detective William Quick of the Florida Division of Insurance Fraud stated, “Greed is the primary force behind everything with insurance fraud. It all comes down to money.”

The full report is available here.

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