Today we experienced a historic moment in Florida Personal Injury Protection law. The 4th District Court of Appeals (4th DCA) ruled in favor of Medical Providers across the State of Florida. Allstate has lost the year-long battle at the District Court of Appeal level. Your clinic may be entitled to hundreds upon thousands of dollars due to Allstate’s improper reimbursements if Allstate reimbursed you pursuant to the Medicare Fee Schedule or the Workers Compensation Fee Schedule in connection with PIP medical treatment you/your facility provided. Please see below for a review of the 4th DCA’s decision.
Please do not hesitate to call our office to discuss this monumental decision at (561) 623-3681.
Our Advice:
SEND US ANY ALLSTATE file or bill you may have in your office. We are filing Motions and gearing up to proceed with resolving all outstanding Allstate suits. DO NOT WORRY, you are not late!
If you would like us to submit your Allstate PIP Suits/Files/Bills, please contact Liliana Davidson, Business Development and Client Relations Manager at (561) 623-3681. We are here to help.
The following is a summary of the issue:
What was at issue?
Thirty-two consolidated PIP cases were brought by medical providers against Allstate Insurance Company. The main issue in the appellate case was whether or not Allstate Insurance Company’s PIP policy was legally sufficient to authorize Allstate to apply the fee schedule reimbursement limitations set forth in Section 627.736(5)(a)(2). Florida Statutes Section 627.736(5)(a)(2) contains all of the fee schedules (i.e. Medicare, Workers’ Compensation, etc.) that an insurer may elect to utilize. In other words, did Allstate’s insurance policy clearly and unambiguously elect to pay via the various fee schedules?
Allstate had two reimbursement choices:
1) Allstate could have elected to pay pursuant to Florida Statutes Section 627.736(5)(a)(1). Section(5)(a)(1) contains different factors to consider in determining a reasonable reimbursement.
2) In 2008, the statute added an additional method of calculating reasonableness. (5)(a)(2) allows insurers to limit reimbursement to 80% of maximum charges, many of them connected to the Medicare Fee Schedules. However, the latter amendment requires both a clear and unambiguous election of the various fee schedules.
(5)(a)(1) is a reasonableness inquiry while (5)(a)(2) is permissive and offers insurers a choice in limiting reimbursements based on the Medicare fee schedules.
Arguments by the Medical Providers:
The Medical Providers argued the language contained in the below endorsement is ambiguous. They further argued that the “subject to” provision did not make a clear election of any reimbursement method. Furthermore, the word “shall” did not make it clear whether the fee schedule method was chosen.
Arguments by Allstate:
Allstate argued the word “shall” constituted election of the fee schedule method of reimbursement. Allstate claimed that they clearly provided notice of their own intent to limit reimbursements in accordance with the Fee Schedules.
4TH DCA’S Opinion:
Today the 4th DCA agreed with the Medical Providers! The words contained in Allstate’s endorsement/policy were too vague and ambiguous. The word “shall” generally references the PIP statute as a whole and fails to mention any application of a specific reimbursement method. The word “shall” did not add clarity to whether or not Allstate chose to utilize the fee schedule payment method or whether it’s merely acknowledging it may do so.
Lastly, dozens of courts throughout Florida are divided as to whether or not Allstate’s policy language is legally sufficient. “If Judges, learned in the law, can reach so diametrically conflicting conclusions as to what the language of the policy means, it is hard to see how it can be held as a matter of law that the language was so unambiguous that a layman would be bound by it.” State Farm Fire & Casualty Insurance Co. v. Deni Associates of Florida, Inc., 678 So. 2d 397, 408 (Fla. 4th DCA 1996).
RELEVANT ALLSTATE POLICY SECTIONS
Allstate’s policy provided the following information regarding PIP benefits:
Allstate will pay to or on behalf of the injured person the following benefits:
- Medical Expenses
Eighty percent of all reasonable expenses for medically necessary medical, surgical, X-Ray, Dental, and rehabilitative services, including prosthetic devices, and medically necessary ambulance, hospital, and nursing services.
An endorsement to the policy provides the following:
Limits of Liability
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… including but not limited to, all fee schedules. (Emphasis Added).
