19 Fla. L. Weekly Supp. 947a
Online Reference: FLWSUPP 1911WATT
Insurance -- Personal injury protection -- Coverage -- Emergency services -- Deductible -- Because insurer is mandated by statute to reserve $5,000 for emergency medical service providers, insurer should not have applied claim filed by medical provider within that classification to deductible
EMERGENCY PHYSICIANS OF CENTRAL FLORIDA, LLP, as assignee of Tina Watts, Plaintiff, v. DIRECT GENERAL INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 2011-SC-2288. July 16, 2012. Donald L. Marblestone, Judge. Counsel: Robert D. Bartels, Bradford Cederberg, P.A., Orlando, for Plaintiff. Neil Andrews, Adams & Diaco, P.A., Orlando, for Defendant.
ORDER GRANTING PLAINTIFF'S MOTION FOR
FINAL SUMMARY JUDGMENT AND
DENYING DEFENDANT'S MOTION FOR
FINAL SUMMARY JUDGMENT
THIS MATTER having come before this Honorable Court on Plaintiff's and Defendant's Competing Motions for Partial Summary Judgment and this Honorable Court having heard arguments of counsel on the issue of whether providers of emergency services and care who submit their bill(s) in accordance with Florida Statute § 627.736(4)(c) are entitled to have their bills paid regardless of the existence of a deductible, and the Court being otherwise fully advised in the premises, finds as follows:
1. The issue before the Court is a matter of first impression.
2. The parties stipulated to the facts and the Court hereby adopts the facts.
FINDINGS OF FACT
3. On March 4, 2011, Tina Watts (Watts) was involved in a motor vehicle accident.
4. On March 4, 2011, Watts was insured by Defendant under an automobile insurance policy.
5. The insurance policy provided Personal Injury Protection (PIP) coverage in the amount of $10,000 and the policy had a $1,000 deductible. The policy did not include medical payments coverage.
6. As a result of the March 4, 2011 motor vehicle accident, Watts sustained injuries and received medical treatment.
7. On March 5, 2011, Watts presented to South Lake Hospital wherein she received emergency services and care as defined by Florida Statute § 395.002(9) from Plaintiff, Emergency Physicians of Central Florida, LLP, the Emergency Department Physicians who serve the Orlando Health System, including South Lake Hospital.
8. Plaintiff charged $446 for the emergency services and care provided to Watts on March 5, 2011.
9. Defendant was notified of the motor vehicle accident on March 7, 2011.
10. On March 23, 2011, Defendant received Plaintiff's bill for date of service March 5, 2011, which was within thirty (30) days of the date Defendant received notice of the motor vehicle accident.
11. Defendant allowed the Plaintiff's charge of $446 in full. However, Defendant applied the Plaintiff's charge to the $1,000 deductible.
12. Plaintiff moved for summary judgment alleging that, amongst other things, Florida Statute § 627.736(4)(c) mandated that PIP insurers reserve $5,000 in benefits for payment to physicians, such as Plaintiff who provide emergency services and care, thereby precluding Defendant from applying the bill to the deductible when the bill was received within thirty (30) days from the notice of accident.
CONCLUSIONS OF LAW AND RULING
13. It is well settled that in attempting to discern legislative intent, courts first look to the actual language used in the statute. Saleeby v. Rocky Elson Construction, Inc., 3 So. 3d 1078 (Fla. 2009) [34 Fla. L. Weekly S106a]; Vreuls v. Progressive Employer Services, 881 So. 2d 688 (Fla. 1st DCA 2004) [29 Fla. L. Weekly D1990b]. Additionally, when a statute is clear and unambiguous, the plain and ordinary meaning must control, unless this leads to an unreasonable result or a result clearly contrary to legislative intent. Id.
14. On January 1, 2008, the Legislature revived the PIP statute which created for the first time a mandatory set aside of $5,000 for payment of bills submitted by a special class of providers. Florida Statute § 627.736(4)(c) states in relevant part:
Upon receiving notice of an accident that is potentially covered by personal injury protection benefits, the insurer must reserve $5,000 of personal injury protection benefits for payment to physicians licensed under chapter 458 or chapter 459 or dentists licensed under chapter 466 who provided emergency services and care, as defined in s. 395.002(09), or who provide hospital inpatient care. The amount required to be held in reserve may be used only to pay claims from such physicians or dentists until 30 days after the date the insurer receives notice of the accident. After the 30-day period, any amount of the reserve for which the insurer has not received notice_of a claim from a physician or dentist who provided emergency services and care or who provided hospital inpatient care may then be used_by the insurer to pay other claims. The time periods specified in paragraph (b) for required payment of personal injury protection benefits shall be tolled for the period of time that an insurer is required by this paragraph to hold payment of a claim that is not from a physician or dentist who provided emergency services and care or who provided hospital inpatient care to the extent that the personal injury protection benefits not held in reserve are insufficient to pay the claim. This paragraph does not require an insurer to establish a claim reserve for insurance accounting purposes.
15. The Court agrees with Plaintiff and finds that the language of Florida Statute § 627.736(4)(c) is clear and unambiguous. PIP insurers must reserve $5,000 of PIP benefits for payment to physicians licensed under the stated chapters of Florida Statute § 627.736(4)(c) and the $5,000 may only be used to pay claims for such physicians until 30 days after the date the insurer receives notice of an accident.
16. The Legislature did not address the deductible and/or the application of a deductible to the selected group of emergency medical providers in Florida Statute § 627.736(4)(c).
17. Based on the plain language of the statute, Plaintiff satisfied all of the requirements set forth in Florida Statute § 627.736(4)(c) and therefore Defendant was obligated to reserve benefits for payment to Plaintiff and should not have applied Plaintiff's bill to the deductible.
18. Therefore the Plaintiff's bill should have been paid from the mandated $5,000 reserve.
19. Accordingly, the Court Grants Plaintiff's Motion for Partial Summary Judgment and Denies Defendant's Motion for Partial Summary Judgment.
20. Following the summary judgment hearing, the parties stipulated that in this case the Plaintiff's services were reasonable, related and medically necessary and that the Plaintiff's charge was reasonable.
21. Based on the parties stipulation, there are no remaining issues of fact in dispute and Plaintiff is entitled to Final Summary Judgment as a matter of law.
22. Final Judgment is hereby granted in favor of Plaintiff, Emergency Physicians of Central Florida, LLP, a/a/o Tina Watts, wherein Plaintiff shall recover from Defendant, Direct General Insurance Company, the sum of $356.80 plus 6% interest in the amount of $28.27 for a total sum of $385.07 for which sum let execution. Post judgment interest of 4.75% per annum shall be due on this judgment pursuant to Fla. Stat. § 55.03.
23. The Court finds Plaintiff is entitled to reasonable attorney's fees and costs. The Court reserves jurisdiction to determine the amount of Plaintiffs attorney's fees and costs pursuant to Fla. Stat. §§ 627.736, 627.428 and 57.041.
* * *
19 Fla. L. Weekly Supp. 948a
Online Reference: FLWSUPP 1911SAIN
Insurance -- Personal injury protection -- Coverage -- Emergency services -- Deductible -- Because insurer is mandated by statute to reserve $5,000 for emergency medical service providers, insurer should not have applied claim filed by medical provider within that classification to deductible
EMERGENCY PHYSICIANS OF CENTRAL FLORIDA, LLP, as assignee of Oriol Saintilma, Plaintiff, v. DIRECT GENERAL INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 2011-SC-002170. July 16, 2012. Donald L. Marblestone, Judge. Counsel: Robert D. Bartles, Bradford Cederberg, P.A., Orlando, for Plaintiff. Neil Andrews, Adams & Diaco, P.A., Orlando, for Defendant.
ORDER GRANTING PLAINTIFF'S MOTION FOR
FINAL SUMMARY JUDGMENT AND
DENYING DEFENDANT'S MOTION FOR
FINAL SUMMARY JUDGMENT
ORDER GRANTING PLAINTIFF'S MOTION FOR
PARTIAL SUMMARY JUDGMENT AND DENYING
DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
THIS MATTER having come before this Honorable Court on Plaintiff's Motion For Partial Summary Judgment Re: Defendant's Affirmative Defenses Number Five (5) And Number Six (6) (Indicated Within Defendant's Answer & Affirmative Defenses As Paragraphs Numbered Fifty-Two (52) And Fifty-Three (53) Respectively) Pursuant To Fla. R. Civ. P. 1.510(c) And Memorandum Of Law In Support Thereof and Defendant's Motion For Summary Judgment and this Honorable Court having heard arguments of counsel on April 16, 2012 and being otherwise fully advised in the premises, it is hereby,
ORDERED AND ADJUDGED that:
1. This is a claim for PIP benefits arising out of a motor vehicle collision that occurred on or about January 20, 2009. Daytona Chiropractic Clinic, LLC (hereinafter referred to as "Plaintiff") rendered chiropractic services to USAA Casualty Insurance Company's (hereinafter referred to as "Defendant") insured (Joseph Gass) following the January 20, 2009 date of loss.
2. On February 3, 2009, Joseph Gass (hereinafter referred to as "Mr. Gass") first presented to Plaintiff for treatment and services due to the injuries Mr. Gass sustained in the motor vehicle collision of January 20, 2009.
3. Plaintiff submitted a Notice of Initiation of Treatment to Defendant pursuant to Fla. Stat. §627.736(5)(c) with a postmark date of February 11, 2009.
4. Plaintiff submitted said Notice of Initiation of Treatment within twenty-one (21) days of the first date of service pursuant to Fla. Stat. §627.736(5)(c)1.
5. Defendant received Plaintiff's timely submitted Notice of Initiation of Treatment on February 14, 2009.
6. On September 1, 2009, Plaintiff rendered chiropractic services to Mr. Gass due to the injuries Mr. Gass sustained in the motor vehicle collision of January 20, 2009. Plaintiff subsequently billed Defendant for the September 1, 2009 treatment and services rendered to Mr. Gass.
7. Plaintiff's statement of charges for treatment and services rendered to Mr. Gass on September 1, 2009 was postmarked on October 13, 2009, less than seventy-five (75) days following the September 1, 2009 date of service.
8. The statement of charges for the treatment and services rendered to Joseph Gass on September 1, 2009 was received by Defendant on October 15, 2009.
9. To date, Defendant has failed to pay for the treatment and services provided by Plaintiff to Mr. Gass on September 1, 2009.
10. Fla. Stat. §627.736(5)(c)1., reads as follows:
"With respect to any treatment or service, other than medical services billed by a hospital or other provider for emergency services as defined in s. 395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 35 days before the postmark date or electronic transmission date of the statement, except for past due amounts previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement. The injured party is not liable for, and the provider shall not bill the injured party for, charges that are unpaid because of the provider's failure to comply with the paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable." Fla. Stat. §627.736(5)(c)1.(2008-2011)(emphasis added).
11. Counsel for the Defendant argues that the opinion of Premier Plus Healthcare, a/a/o Torres Claudia v. United Services Automobile Association, 8 Fla. L. Weekly Supp. 868a (County Court, Broward County, September 10, 2001) should control this issue. The Court finds this case unpersuasive and in conflict with the clear and unambiguous language of the statute. The Premier Plus court sets forth no analysis for its ultimate conclusion that a Notice of Initiation of Treatment only applies to "that first statement." Id.
12. Counsel for the Plaintiff presents two cases that are on point, Hands For Health, Inc., a/a/o Mamerto Marte v. Allstate Insurance Company, 11 Fla. L. Weekly Supp. 128b (County Court, Orange County, December 12, 2003) and Warren v. State Farm Mutual Auto. Ins. Co., 899 So. 2d 1090 (Fla. 2005) [30 Fla. L. Weekly S197b]. The Court finds that these two cases offer both guidance and analysis of the issue in this matter which is one of first impression for this Court.
13. "The clear language of the statute begins with the phrase 'With respect to any treatment or services. . .'. The statute then goes on to set forth the time limitations and exceptions thereto regarding the statement of charges for any treatment or services." Hands For Health, Inc., 11 Fla. L. Weekly Supp. 128b(emphasis in original). The Hands For Health court was addressing Fla. Stat. §627.736(5)(b)(2000); the language of Fla. Stat. §627.736(5)(c) (2008-2011) is fundamentally unchanged from its earlier counter-part with the exception of the number of days permitted for submission of a statement of charges once a timely Notice of Initiation of Treatment is submitted to the insurer. The earlier Fla. Stat. §627.736(5)(b)(2000) allowed sixty (60) days from the date of treatment where as the current Fla. Stat. §627.736(5)(c) (2008-2011) permits seventy-five (75) days for the postmarking of the statement from the date of service on the statement of charges.
14. "The statute does not distinguish the first date of treatment from any other date of treatment or services and, therefore, Section 627.736(5)(b) Florida Statutes (2000) applies to charges for all dates of treatment related to the date of loss and patient for which the provider makes a claim." Hands For Health, Inc., 11 Fla. L. Weekly Supp. 128b(emphasis added). "Reference to the 'first examination or treatment' in Section 627.736(5)(b) Florida Statutes (2000), merely provides a point from which to measure the 21 days within which healthcare providers must submit a notice of initiating treatment to obtain the 30 day extension." Id. This extension is measured from the original thirty (30) days indicated within the previous Fla. Stat. §627.736(5)(b) as the time limitation for submitting statement of charges wherein no Notice of Initiation of Treatment applies. Under the current version of the statute, Fla. Stat. §627.736(5)(c)(2008-2011), said extension has been increased to forty (40) days over the thirty-five (35) days allowable wherein no Notice of Initiation of Treatment applies. There has been no change to the twenty-one (21) day time limitation for submission of the Notice of Initiation of Treatment. The "first examination or treatment" is used simply as a reference point for the twenty-one (21) day time limitation, if the Legislature wanted to limit the Notice of Initiation of Treatment extension to only the "first examination or treatment" it would have done so.
15. Further, the Court finds the reasoning of the Florida Supreme Court in the case of Warren v. State Farm Mutual Auto. Ins. Co., 899 So. 2d 1090 (Fla. 2005) [30 Fla. L. Weekly S197b] compelling to this issue. When addressing the constitutionality of Fla. Stat. §627.736(5)(b)(1999), the Florida Supreme Court indicated that under Fla. Stat. §627.736(5)(b)(1999), predecessor to Fla. Stat. §627.736(5)(c)(2008-2011), "a provider who submits a notice of initiation of treatment within twenty-one days of the first examination or treatment of the patient may then have up to sixty days [seventy-five days under the current statute] to submit claims to the insurer." Id.(emphasis added). The Florida Supreme Court's use of the word "claims" in this Notice of Initiation of Treatment context relates to all claims (i.e., all dates of service). This is clear by the court's previous use of the word "claims" when speaking about bills that are not subject to the statutory Notice of Initiation of Treatment extension. Id at 1094.
16. The clear and unambiguous language of Fla. Stat. 627.736(5)(c)1., reads "[w]ith respect to any treatment or service" the statement of charges "may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement." Fla. Stat. §627.736(5)(c)1. (2008-2011)(emphasis added). Consequently, any date of service for treatment and service rendered to Mr. Gass by Plaintiff for the injuries Mr. Gass sustained in the motor vehicle collision of January 20, 2009 were permitted to be billed to Defendant and considered timely so long as the postmark date on the bill ("statement of charges") indicated a date no later than seventy-five (75) days after the date of service included on the bill ("statement of charges"). The Court can not read into Fla. Stat. §627.736(5)(c)1. (2008-2011) that the Notice of Initiation of Treatment only applies to the first date of treatment, to do so would be in derogation of the clear language of the statute.
17. A timely Notice of Initiation of Treatment was submitted within twenty-one (21) days of Plaintiff's initial date of treatment of Mr. Gass. Consequently, Plaintiff was permitted the forty (40) day extension of time, permitting Plaintiff to submit the September 1, 2009 statement of charges to Defendant up to seventy-five (75) days following the September 1, 2009 date of service.
18. Plaintiff in no way violated Fla. Stat. 627.736(5)(c) in this matter as Plaintiff's billing for the treatment and services rendered to Mr. Gass on September 1, 2009 was timely and properly submitted to Defendant for payment. To date, Defendant has failed to pay the timely and properly submitted bill for date of service September 1, 2009.
19. Defendant's Motion For Summary Judgment is hereby DENIED.
20. Plaintiff's Motion For Partial Summary Judgment is hereby GRANTED as to Defendant's Affirmative Defense Number Six (6) (indicated within Defendant's Answer & Affirmative Defenses as paragraph number fifty-three (53)) as Plaintiff submitted a timely Notice of Initiation of Treatment and subsequently submitted a proper and timely statement of charges to Defendant for the treatment and services rendered to Mr. Gass on date of service September 1, 2009.
21. The Court hereby reserves ruling on Plaintiff's Motion For Partial Summary Judgment as to Defendant's Affirmative Defense Number Five (5) (indicated within Defendant's Answer & Affirmative Defenses as paragraph number fifty-two (52)) which ruling will not conflict with the language of this Order.
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