Win for insurers: Court finds no obligation to pay full PIP expenses
Health care providers claimed an ambiguous PIP policy meant their patients were entitled to full reimbursement for medical treatments.
A group of South Florida medical providers who challenged an insurance company’s interpretation of its car crash coverage lost its battle on Wednesday, Sept. 23, when the Fourth District Court of Appeal found insurers aren’t obligated to fully reimburse patients for post-crash medical expenses.
It was an appeal involving personal injury protection, or PIP, insurance benefits, which cover medical expenses after a Florida car accident, regardless of who was at fault for the injury.
Wednesday’s ruling covers multiple cases consolidated before Broward Circuit Judges Robert W. Lee and Florence Taylor Barner, who sided with the insurers but certified a question of great public importance to Florida’s Fourth District Court of Appeal.
80% or full reimbursement?
The appellate court had to decide whether a PIP insurance policy requires insurance companies to pay more than 80% of a statutory $10,000 fee limit if that policy has a provision for the total limit of benefits, based on the difference between a deductible and total expenses.
Health care providers Plantation Open MRI LLC, MR Services I Inc. and Upright Open MRI LLC claimed an ambiguous PIP insurance policy meant their patients were entitled to full reimbursement for medical treatments.
The companies highlighted a “limits of liability” section of the policy, which said:
“The amount of any deductible stated on the declarations page shall be deducted from the total amount of all loss and expense incurred by or on behalf of each person to whom the deductible applies and who sustains bodily injury as the result of any one accident. If the total amount of such loss and expense exceeds such deductible, the total limit of benefits we are obligated to pay shall then be based on the difference between such deductible amount and the total amount of all loss and expense incurred, subject to the $10,000 limit of benefits.”
But insurers Infinity Indemnity Insurance Co., Infinity Auto Insurance Co. and Infinity Assurance Insurance Co. argued Florida Statute section 627.736(5)(a)1 only required them to cover up to 80% of the $10,000 limit for emergency services.
The appellate panel found Florida law requires it to interpret insurance contracts “according to the entirety of its terms and conditions.” It found that case law said that “true ambiguity does not exist merely because a contract can possibly be interpreted in more than one manner.”
Under that reasoning, the opinion said the policy wasn’t ambiguous.
“When the policy is read in its entirety, the section in dispute clearly limits the overall liability and explains how any applicable deductible is applied,” Wednesday’s opinion said. “It does not create a separate payment obligation.”
Analyzing the paragraph at issue in the contract, the appellate panel found that by focusing on the object word “benefits,” the providers had ignored that the adjective “total” modified the noun “limit.”
“Instead, the providers assert an ambiguity by reading this sentence as if the noun—limit—was not there, substituting the object — benefits — as if it was the noun,” the opinion said. “By doing so, the providers have added a meaning that is not present in the policy’s text.”
Fourth District Court of Appeal Judge Edward Artau wrote the ruling, with Judges Dorian Damoorgian and Alan Forst concurring.
Miami solo practitioner Douglas H. Stein represents the providers, while Gladys Perez Villanueva and Garrett A. Tozier of Shutts & Bowen’s Miami and Tampa offices represent the insurers. Suzanne Y. Labrit also represented the insurers but withdrew after oral argument. They did not immediately respond to a request for comment.
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