According to Law360, on Wednesday, April 19th Florida’s Third District Court of Appeal retroactively applied a state Supreme Court decision involving Allstate Insurance Co.’s personal injury protection policy language regarding the use of the Medicare fee schedules, overriding a lower court’s ruling and handing Allstate the win. After denying the insurer’s request for review of a circuit court appellate division’s ruling in favor of medical provider Hallandale Open MRI LLC last September, the court reversed course, applying the Supreme Court’s January decision in Allstate v. Orthopedic Specialists.
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Florida Highway Patrol Trooper David Casillas was arrested on Tuesday, February 28th and charged with organized fraud, filing a false insurance claim and official misconduct after trying to help a friend cover up a traffic crash that occurred in June of 2015. FHP fired Casillas in January as a result of the investigation which lasted over a year.
During the investigation, it was discovered that Casillas had written a false report for a bogus insurance claim submitted by his friend, dentist Jesus Del Valle. The insurance claim was submitted as a result of damage the dentist had done to his vehicle when he sideswiped a landscaping crew and kept driving.
Del Valle’s crash left Yoel Montero, a gardener with Lewis Tree Service, with a traumatic head injury and severe injuries to his right leg. The false insurance claim alleges that the accident happened a week later than it actually happened and that he had crashed the SUV into a palm tree instead of a landscaping crew.
The key to breaking the case was the fact that Del Valle’s 2015 Land Rover needed a new passenger-side mirror which could only be ordered from Range Rover manufacturers. Only one such had been sold in that time period and it was to Del Valle’s mechanic (and friend) Ariel Perera who performed the repair on his vehicle. Perera also allegedly submitted inflated invoices to Del Valle’s insurance company as well as charged the company for replacement parts that were never actually replaced. He is also facing charges with Del Valle and Casilla.
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The Florida Supreme Court recently heard oral argument in Allstate Insurance Company v. Orthopedic Specialists, No. SC15-2298. At issue was an appeal of a ruling that it wrongfully limited its reimbursements under Medicare fee schedules for motorists’ personal injury protection (PIP) claims.
Allstate’s policy language has been found to be exceedingly clear and concise by the majority of appellate courts across the state. A ruling affirming the Fourth District Court of Appeals decision would only serve to blindside Florida’s citizens with additional bills for costly co-payments while also limiting the amount of coverage available to them.
While we wait for a final opinion, industry professionals have been closely watching the court for any and all clues. Politics of the high court aside, what “shall” we analyze to determine how the justices will rule?
One such clue seems to be overlooked, yet is hiding in plain sight. On the very day that the court heard oral argument in Allstate v. Orthopedic Specialists the court issued a Per Curiam Opinion amending the Florida Rules of Civil Procedure in which the word “shall” was stricken over 200 times. See In Re: Amendments to the Florida Rules of Civil Procedure No. SC16-155. Ironically and perhaps persuasively, the court writes unanimously that “[t]he amendments shall become effective January 1, 2017, at 12:01 a.m.” (emphasis mine.)
More recently, numerous Per Curiam Opinions amending various procedural and administrative rules have been issued. They have seen the court continue to favor “shall”. Amendments to the Rules of Criminal Procedure, Rules of Appellate Procedure, Code of Judicial Conduct and Small Claims Rules did not remove any “shall” provisions.
Pouring over minor amendments by the high court with no clear answer, perhaps we are left to channel Judge May’s epic dissent in the Fourth District Court of Appeals Opinion in which she found Allstate’s policy language to be unambiguous and compliant. While accusing the medical providers of leading the majority down the yellow brick road she writes frustratingly, “As the Pope once asked Michelangelo during the painting of the Sistine Chapel: “When will there be an end?”
We “shall” know soon.
According to WFTV Action 9 News, Robert Wolfe, former Tavares Mayor admitted to committing insurance fraud as part of a plea deal he made with the state. Wolfe was arrested in July after investigators found that Wolfe had reported to the insurance company that he had rented a home for $2,350 a month and had to board his dogs for $1,800 a month due to a leak in his home that needed to be repaired. However, investigators found that Wolfe never moved into the rental.
Wolfe will be placed on probation for 18 months and has been ordered to pay all investigative and court costs. He was also removed from his mayoral seat in July and has since resigned. Once Wolfe completes the 18 month pretrial intervention program, charges will be dismissed.
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On August 28, 2016, the Sun Sentinel reported the arrest of two women and a man who were part of a South Florida ring that staged fake car crashes. The ring aimed to defraud insurance companies by charging for massage therapy and chiropractic services to victims that did not need the medical treatment.
The defendants, Guillermo Garcia, 46; Mayre Lopez, 39; and Taymi Gonzalez, 35, were said to have collected more than $1.6 million over a span of two years from different insurance companies, including Allstate Insurance Company, Geico, Infinity, Metlife, Progressive, State Farm and Travelers of Florida. They all pleaded not guilty and are currently awaiting trial.
According to the indictment filed on August 4, the ring began in December 2012 and was carried out until September 2014 in Miami-Dade and other areas of South Florida. The indictment stated that the defendants had conspired to send fraudulent information and billing through the mail to auto insurance companies for alleged medical treatment from the clinic, Rehabilitation Tomasa.
According to the indictment, Gonzalez, Lopez and Garcia not only helped prepare fraudulent claims to insurance companies to validate treatment at Tomasa but also took part in training the ‘victims’ on what they should say to insurance representatives to deflect suspicion. The indictment stated, “ Garcia, Lopez and Gonzalez would deposit the checks into bank accounts they controlled and then convert the proceeds to cash in order to pay the recruiters, accident participants and clinic employees, and to enrich themselves.”
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The Third District Court of Appeal recently ruled in favor of Allstate in a dispute over personal injury protection (PIP) reimbursements for medical services following an auto accident.
The Third DCA now agrees with two other appellate courts: the First in Tallahassee and the Second in Lakeland. However, as a result of a contrary ruling from the Fourth DCA in West Palm Beach, the dispute is set for oral argument before the Florida Supreme Court in September.
The dispute focuses on language in auto insurance policies that spells out if the insurer properly elected to pay medical bills based upon the Medicare fee schedules enumerated in the PIP statute. Florida courts have said the insurance policies must unambiguously elect the use of the statutory fee schedules in limiting reimbursement for PIP claims.
The Third DCA case came from five consolidated appeals. All five concerned a medical provider, as assignee of a person insured by Allstate, suing Allstate for payment of medical bills under the PIP statute. In each case the policy had identical policy language stating: “Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736 … including but not limited to, all fee schedules.”
Third DCA Judge Thomas Logue, who wrote the opinion, agreed with the opinions in the other two appellate courts finding for Allstate and noted that he agreed with Judge Melanie May’s dissent in the Fourth DCA ruling. Logue disagreed with medical providers, who insisted the words “subject to” were ambiguous.
“A decision that the term ‘subject to’ is ambiguous would mean that the Judicial Code and many provisions of Florida Statutes were legally meaningless and in need of redrafting,” Logue wrote. “We decline to adopt such a counter-intuitive interpretation of a common and well-understood legal expression. The use of the phrase ‘subject to’ in the policy places the insured on notice of the limitations elected by Allstate.”
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A Cuban national was sentenced to more than three years in prison after pleading guilty to a $2.6 million healthcare fraud against Medicare, according to the Department of Justice.
Ubert Guillermo Rodriguez, 47, pleaded guilty to conspiracy to commit healthcare fraud in March 2016. Rodriguez, who had been a fugitive since his indictment in 2013 until his arrest in 2015, was also ordered to pay $918,000 in restitution and forfeit another $918,000. When federal authorities served a seizure warrant on Rodriguez’s bank account, they seized more than $243,000.
Rodriguez owned G.R. Services Equipment & Supplies near St. Petersburg. The company was supposed to supply medical equipment to Medicare beneficiaries. Rodriguez admitted his company submitted nearly $2.6 million in false claims to Medicare from May 2013 to June 2013. During that period, Rodriguez was reimbursed for hundreds of thousands of dollars for sterile collagen dressings and negative pressure wound therapy electrical pumps. Yet those items were never prescribed by doctors or given to beneficiaries.
The case was part of the Medicare Fraud Strike Force by the U.S. Attorney’s Office of the Middle District of Florida.
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Paul Michael Gabe, attorney in the Miami office and Mark D. Bartle, attorney in the Deerfield Beach office, obtained a favorable ruling from the Honorable Robert W. Lee of the Seventeenth Judicial Circuit in and for Broward County on behalf of a Roig Lawyers’ client/insurer in a case of first impression. At issue was whether a post-suit payment of medical benefits is a Confession of Judgment, which would entitle Plaintiff to statutory attorney’s fees and costs.
The Plaintiff submitted medical bills to Defendant. Medical benefits were exhausted at $2,500.00 as no Emergency Medical Condition (EMC) declaration was received by Defendant. Defendant’s Explanation of Benefits indicated exhaustion of benefits due to a lack of an EMC declaration. Subsequently, Plaintiff sent a demand for additional payment. Defendant responded, clarifying that benefits were exhausted at $2,500.00 and asked Plaintiff to provide an EMC declaration. Plaintiff did not respond and later filed a lawsuit. Defendant raised exhaustion of medical benefits as a defense. On the eve of Court ordered arbitration, Plaintiff served an EMC declaration to Defendant, which was dated prior to the lawsuit. Defendant paid the remainder of the claim within thirty (30) days of receipt of the EMC declaration. Gabe and Bartle moved the Court to rule that Defendant’s post-suit payment of medical benefits is not a Confession of Judgment and that Plaintiff should not be entitled to statutory attorney’s fees and costs. The court agreed that Defendant properly exhausted benefits at $2,500.00, and properly made an additional payment upon receipt of the EMC declaration. As such, Defendant’s post-suit payment was not a Confession of Judgement.
“We are pleased with the outcome of this case and the precedent that it sets for Private Passenger Automobile (PPA) insurance companies across the state in similar cases,” said Gabe and Bartle.
Residents of Duval County are being advised to remain vigilant for criminals soliciting residents to participate in a scam to defraud insurance companies.
News Channel WJXT of Jacksonville, Florida has reported an increase in the number of residents calling their newsroom to report potential scammers going door-to-door asking for a copy of their insurance policy.
According to the Coalition Against Insurance Fraud, this scam involves windshield repair shops convincing unsuspecting residents to replace their windshield even though little to no damage exists. These repair shops often offer incentives for residents in the form of cash or other gifts.
Insurance professionals have seen a marked increase in the number of windshield replacement claims over the past 5 years. Gil Smith, News Channel WJXT’s crime and safety analyst recommends that if you do have a damaged windshield to contact your insurance company first. Further, he recommends that you only seek a vendor that your insurance company approves.
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