Florida Court of Appeal Allows Injured Motorist to Pursue Additional PIP Payments to Medical Providers

Personal Injury Protection (PIP) is a benefit offered to motorists in their mandated auto insurance coverage. In recent years, the types of benefits paid were narrowed by statute, and those injured in a car accident have experienced greater challenges to getting providers paid. If the PIP benefits fail to cover the cost of treatment, the medical provider can seek the difference from the insured. This scenario is found in a recent Fourth District case (No. 4d16-1013). The plaintiff’s auto insurer paid some of the medical bills, but not as much as the the injured person expected. The injured person was billed the remainder.  The injured person asked the court for a declaratory judgment from the civil court system to show the auto insurer did not use the proper method when determining the reasonable amount to reimburse. The injured person alleged this calculation was not in her policy and asked the court to order the insurer to reimburse her and others like her.

Section 627.736 of the Florida Statutes allows insurers to choose between two methods to assess PIP medical reimbursements. The insurer can pay a reasonable amount, following the guidelines in subsection (5)(a)(1), or it can choose to apply the Medicare fee schedule, following the guidelines in (5)(a)(2) of the statute. If an insurance company chooses the latter method, it must provide notice to the insured that it is using this schedule. If this method is chosen, the statute prohibits providers from billing or collecting payments from the insured. In this lawsuit, the insurance company readily acknowledged that it did not choose the method relying on the Medicare fee schedule. The injured woman argued that they followed the fee schedule anyway and that she was inappropriately billed by the medical centers that provided her care. The lower court granted the insurer’s motion to dismiss.

In its review, the appellate court noted that subsection (5)(a)(1) allows the insurer to pay providers a “reasonable amount,”and a determination of what is reasonable centers around the facts and circumstances of the case. Subsection (5)(a)(2) permits insurers to cap the payments at 80% of the maximum charges granted by the Medicare Part B fee schedules. For guidance, the court looked at a similar case filed by medical providers earlier this year, which also alleged the same insurer was calculating and paying reimbursements solely using the Medicare fee schedule. This lawsuit also alleged the insurer was not providing notice to the insured in the policy of its intent to use the Medicare fee schedule. The Court chose to follow the same course of action, reversing and remanding the case for reinstatement of the complaint. The court reasoned that the question to ask was whether the use of Medicare fee reimbursement rates to calculate provider rates was reasonable and therefore authorized under (5)(a)(1). The court felt it was inappropriate for the trial court to dismiss, and it should give full consideration to the evidence presented on whether or not the Medicare rates could be the lone source in determining what was a reasonable reimbursement.

The appellate court also noted that the injured woman agreed in her policy to pay the difference between the reasonable amount covered by PIP and the cost of services. The court said the question related to appropriate damages wasn’t whether she should have been billed by the medical providers, but whether the remainder was too high because of the unreasonable rate used by the insurance company. The Fourth District concluded the best the appellant could expect was a refund of the difference between the amount paid to the provider and the re-calculated amount deemed reasonable under subsection (5)(a)(1).

When a car accident happens, the last thing you want to handle is problems with PIP payments to medical providers. The South Florida personal injury attorneys at Donaldson & Weston can help you with your car accident claim and seek to maximize the benefits you should receive under your auto insurance policy. Call today for a free, confidential consultation at 772-266-5555 or 561-299-3999.

More Blog Posts:

Florida District Appellate Court Reviews Future Medical Expenses in Multi-Car Accident Case, Florida Injury Lawyer Blog, November 28, 2016

Federal Circuit Court of Appeal Declines to Find Equitable Tolling in Slip and Fall Case, Florida Injury Lawyer Blog, October 21, 2016