The Florida Court of Appeal, Fourth District, has issued a decision in a case involving the amount an insurer must pay a health care provider who has treated an insured covered by a no-fault insurance policy that directly conflicts with a decision last month by the Fifth District.
The Fourth District explained that the question it had to decide was:
Pursuant to Sections 627.736 and 627.739, Florida Statutes (2013), is an insurer required to apply a policy deductible to the total amount of a provider's invoices to an insured prior to applying any fee schedule found in Section 627.736, Florida Statutes?
The Fourth District answered the question in the negative.
In the context of personal injury protection benefits, the Fourth District said, the legislature mandated a provider that has treated an injured party charge the "insurer and injured party only a reasonable amount." In the appellate court's view, to apply the fee schedule to the billed charges only after applying the deductible, as the provider argued, "would allow the provider to recover different amounts depending on the amount of the deductible" and also would allow the provider "to recover more than the amount found to be reasonable in the fee schedule."
Accordingly, it held that an insurer must reduce the provider's charges to the statutorily-approved permissive fee schedule before applying the deductible.
The Fourth District certified conflict with the Fifth District in Progressive Select Insurance Co. v. Florida Hospital Medical Center a/a/o Jonathan Parent. See, Florida Supreme Court Asked to Resolve No-Fault Issue Dividing Florida Courts.
The case is State Farm Mutual Automobile Ins. Co. v. Care Wellness Center, LLC, No. 4D16-2254 (Fla. Ct.App. 4th Dist. March 14, 2018). Attorneys involved include: Nancy W. Gregoire of Birnbaum, Lippman & Gregoire, PLLC, Fort Lauderdale, and Scott E. Danner of Kirwan, Spellacy & Danner, P.A., Fort Lauderdale, for appellant; Marlene S. Reiss of Law Offices of Marlene S. Reiss, Esq., P.A., Miami, Thomas J. Wenzel of Cindy A. Goldstein, P.A., Coral Springs, and Stuart L. Koenigsberg of A Able Advocates-Stuart L. Koenigsberg, P.A., Miami, for appellee; Marlene S. Reiss of Law Offices of Marlene S. Reiss, Esq., P.A., Miami, Thomas J. Wenzel of Cindy A. Goldstein, P.A., Coral Springs, and Stuart L. Koenigsberg of A Able Advocates-Stuart L. Koenigsberg, P.A., Miami, for appellee; Matthew C. Scarfone of Colodny Fass, P.A., Sunrise, for Amicus Curiae, Property Casualty Insurers Association of America; Mac S. Phillips of Phillips|Tadros, P.A., Fort Lauderdale, and David M. Caldevilla of de laParte & Gilbert, P.A., Tampa, for Amicus Curiae, Floridians For Fair Insurance, Inc.