Florida State Appellate Court Addresses PIP Payments to Medical Facility


The Florida Motor Vehicle No-Fault Law is designed to help all of the parties involved in a Florida car accident.  The statute attempts to provide available funds through the purchase of mandated auto insurance to an injured driver or passenger under a policy while minimizing costs to the auto insurer and the insured public at large and adequately paying medical treatment providers.  The statute requires an insurer to reimburse a percentage of reasonable expenses for medically necessary services.  An insurer may choose to limit its payment by utilizing a schedule of maximum charges delineated in section 627.736(5)(a)(1).  If an insurer uses this limitation, it must provide notice to the insured of the policy.

The Second District Court of Appeal reversed a summary judgment for a medical center fighting to receive larger Personal Injury Protection (PIP) payments than the schedule of maximum charges in section 627.736(5)(a)(1)–(5), Florida Statutes (2013).  The appellate court found the language in the auto insurer’s policy clearly and unambiguously elected to limit reimbursement payments and should have been upheld.  The appellate action stems from 19 PIP claims made by parties injured in car accidents in 2013 who were using the same auto insurer.  The insureds all assigned their auto insurance benefits to the medical facility, which then submitted bills to the auto insurer.  The insurer paid a portion of the 19 submitted bills, following their schedule of payment in the policy.  The medical facility disputed these amounts. 

The auto insurer chose to file an action seeking a declaration of rights under the policy and the PIP statute, section 627.736 of the Florida Statutes.  The medical facility countersued, also seeking a declaration of rights and obligations under the auto insurance policy and an injunction to prevent the auto insurer from continuing to limit its payments for charges.  The policy stated they would pay reasonable charges for bodily injuries, in accordance with the PIP statute.  The insurer advised in this policy it would limit the payment of medical expenses described in the insuring agreement to 80% of a properly billed and documented reasonable charge.  The ceiling on the payment was 80% of the schedule of maximum charges, including the use of Medicare coding policies and payment methodologies.

The medical treatment provider argued the insurer must choose between paying either the reasonable charge method of calculation or the schedule of maximum charges.  The provider claimed the auto insurer’s policy included both, thereby relying on an unlawful hybrid method of reimbursement calculation.  The provider concluded the insurer must use the reasonable charge method found in section 627.736(5)(a) of the Florida Statutes.  The appellate court disagreed, finding the policy followed the reimbursement calculation contained within section 627.736(5)(a) and the limitation set forth in section 627.736(5)(a)(1).

The court looked at recent decisions issued by the Supreme Court regarding the calculation of PIP benefit payments.  Those cases dealt with a prior version of the statute, which also offered two different calculations for an insurer to use.  The notice requirement was enacted in 2012, the year before the accidents in this case.  The appellate court first concluded the notice requirement was met by the plain language of the policy.  The court also determined the recent amendments to the method of calculation in 2013 eliminated two mutually exclusive methods of calculating reimbursement payments to the insurer.  The appellate court rejected the provider’s argument that the inclusion of both statutory methods of calculating payment was an “unlawful hybrid,” and it reversed and remanded the case to the lower court.

The auto accident attorneys at Donaldson & Weston have the personal injury experience you need to pursue the benefits you need and deserve from your auto insurance policy.  Call our office today for a free, confidential consultation at 772-266-555 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

Florida Court of Appeal Allows Injured Motorist to Pursue Additional PIP Payments to Medical Providers, Florida Injury Lawyer Blog, May 18, 2017