Florida’s mandatory Personal Injury Protection insurance, or PIP, which is the minimum required auto insurance, has probably generated more civil litigation than any other in body of law I have seen in my 26 years of practicing law. The reason it is so often at the center of hotly contested battles in both trial and appellate courts may be the fact that so many people are affected by what, when, and how much PIP insurance pays to whom after a car, truck, motorcycle, or pedestrian accident in Florida, not to mention payments to doctors, hospitals, and others who provided them medical care.
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This week a PIP case wiggled itself all the way to Florida’s Supreme Court, where the justices were asked to decide if Allstate could limit the amount it paid for medical expenses (related to a Florida car crash) to Medicare’s current fee schedule. Several Florida appellate courts have recognized the disparity between payment under the “fee-schedule method” that pays much lower benefits (commensurate with meager Medicare rates) than would be payable under the “fact-based payment method.”
Florida’s Supreme Court has the jurisdiction to resolve conflicting opinions between district appellate courts.((See art. V, § 3(b)(4), Fla. Const. )) The case stemmed from an appeal, from Florida’s Fourth District Court of Appeal, called Orthopedic Specialists v. Allstate Insurance Co.((177 So. 3d 19 (Fla. 4th DCA 2015).))In that case the court held that Allstate’s PIP policy language was not legally sufficient to authorize Allstate to apply the Medicare fee schedules when paying for their insured’s medical expenses. This opinion conflicted with an opinion from Florida’s First District Court of Appeal, Allstate Fire & Casualty Insurance v. Stand-Up MRI of Tallahassee, P.A.,((188 So. 3d 1, 3 (Fla. 1st DCA 2015).))which held that identical policy language “g[ave] sufficient notice of [the insurer’s] election to limit reimbursements by use of the fee schedules.”
The Supreme Court also found that Allstate’s insurance policy provided “legally sufficient notice” of Allstate’s election to use the Medicare fee schedule to limit reimbursements.(( ALLSTATE INSURANCE COMPANY, Petitioner, vs. ORTHOPEDIC SPECIALISTS, etc., Respondents. Supreme Court of Florida. Case No. SC15-2298. January 26, 2017.)) Here’s why:
Allstate’s policy states that it will pay to an injured person the following benefits:
-80% of Medical Expenses for “medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices, and medically necessary ambulance, hospital, and nursing services.”
However, the following limitations are written in a complex legal mumbo jumbo, which proved confusing to both the trial and appellate courts, not to mention the people who actually bought Allstate insurance:
“Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736, or any other provisions of the Florida Motor Vehicle No-Fault Law, as enacted, amended or otherwise continued in the law, including, but not limited to, all fee schedules.”
To figure this out, the Supreme Court was required not only to interpret the provisions Florida’s Motor Vehicle No-Fault Law–specifically, the PIP statute–but also to interpret Allstate’s insurance policy. An insurance policy is simply a contract to provide insurance, but it is written in the most complex and convoluted way it can be so as to provide insurance companies like Allstate, State Farm, Geico, and others as many ways to get out of paying as possible.
The Supreme Court decided that Allstate’s PIP policy provided legally sufficient notice of its “unambiguous” election to use the permissive Medicare fee schedule in limiting the reimbursements.((Section 627.736(5)(a))) This case will have a significant impact on anyone who sustains an injury from a car, truck, or motorcycle accident in Florida and the payment of their medical bills.
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