Category Archives: Insurance Claims

Geico Sues Florida Health Clinic for ‘Unnecessary’ Massage Claims

As reported by Law360, Geico sued Medical Wellness Services Inc. of Miami, FL for allegedly making $1.2 million in claims for providing medically unnecessary treatments for automobile accident victims who were eligible for coverage under their no-fault insurance policies. According to Geico, some of the claims were for services that were not actually provided and contained billing codes that misrepresented and exaggerated the services.

“The defendants do not now have — and never had — any right to be compensated for the fraudulent services that were billed to Geico through Medical Wellness,” Geico said. Geico claims Medical Wellness Services Inc. submitted claims for massage therapist services which are not reimbursable because Florida law prohibits no-fault insurance reimbursement for massages or other similar services.

According to the suit, the scheme began no later than 2013 and continues to this day. In addition to the request for $1.2 million in damages, Geico is also requesting a declaration from the court saying it will not have to pay any pending fraudulent claims by the health clinic which totals more than $75,000.

Click here for the full story (subscription required).

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Miami-Dade County, Miami-Dade Fraud, Personal Injury Protection, PIP/No Fault

Undercover Investigation Led to Arrests of Bradenton Area Chiropractors

According to ABC Action News, an undercover investigation led to the arrests of two Bradenton area chiropractors and other staff. Detectives say chiropractors Richard Tambe and Yusef Barnes, along with chiropractic assistant Johncina Harrell, performed a fraction of the treatments listed on insurance claims and were billing for treatment never rendered to patients.

The arrests and undercover investigation took place at the Back on Track clinic in Bradenton, Florida. According to the arrest report, all three were booked at the Manatee County Jail on insurance fraud, a third degree felony. Tambe faces 12 counts. Barnes is charged with 8 and Harrell is charged with 13 counts. If convicted each suspect faces as much as 5 years in prison.

Click here for full story.

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Filed under Florida, Insurance, Insurance Claims, Insurance Fraud, Uncategorized

Sunny South Florida, Out-of-State College Students and the question of Vehicle Insurance Coverage

Spring Break, a time where college students from all over the Country flock down to Florida, known by many as the “Spring Break Capital of the World”, looking to have some fun in the sun.

Florida has many Universities, Colleges and other institutions of higher learning that welcome students from other States to attend.

So the question is, does an out-of-state student who attends University or College in Florida for 2 or 4 years now become a resident of Florida because they have decided to live in Florida during this time? Is that out-of-state student now required to register and license their out-of-state vehicle in Florida and obtain the minimum Florida automobile insurance coverage on that vehicle which is $10,000.00 in Personal Injury Protection and $10,000.00 in Property Damage Liability?

Well yes and no.

If the out-of-state student is planning to domicile themselves in Florida then they are required to license their vehicle in Florida and obtain the minimum insurance in order to operate that vehicle on the roads and highways of the State.

However, if the student maintains their residence in another State while they are enrolled as a full-time student in an “institution of higher learning”, then they are exempt from licensing their vehicle and obtaining the minimum insurance on that vehicle during the duration of their enrollment, as long as they have complied with the licensing and insurance requirements of the State for which they are a resident. One less thing for parents to worry about when they watch their babies leave the nest for the first time.

However, what constitutes an “institution of higher learning”.

The Merriam-Webster Dictionary® defines this term as “a college or university”. But what about a trade school, vocational school or cosmetology school? The Federal Government generally defines an ”institution of higher education” as a public or nonprofit educational institution who only admits students who have a high school diploma or have a recognized equivalent certificate such as a General Educational Diploma (GED); is accredited or has pre-accreditation status; awards a Bachelor’s Degree or a 2-years Associates Degree; or, any school that provides not less than a 1-year training program beyond High School, to prepare students for gainful employment in a recognized occupation.[1]

These are inquiries that an insurance company must properly investigate in an automobile accident claim involving a nonresident student in order to determine whether they would be exempt from maintaining the minimum Florida insurance on their vehicle while in Florida or if the insurer may be required to extend that student the minimum insurance under Florida law.

So would your insured qualify for the exemption as a nonresident student?

This article is not intended to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that requires attention.

For additional information, please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com. Stephen G. Mellor is a partner in the Deerfield Beach office of Roig Lawyers who primarily focuses on out-of-state policy claims for insurance carriers. 

[1] 20 U.S. Code § 1001

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Filed under auto insurance, Claims Handling, Florida, Insurance, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP, PIP/No Fault

Will You Have Coverage When You Cross The Line?

Is an automobile insurance company required to extend Florida Personal Injury Protection (PIP) benefits to an insured who resides in another state?

Well yes and no.

An automobile insurer who sells automobile insurance policies in Florida and the nonresident insured’s state is required to extend the minimum Florida Personal Injury Protection (PIP) benefits of $10,000.00 to the insured if they are involved in a motor vehicle accident in Florida, but only if they qualify under Florida law.

To qualify, the nonresident insured’s vehicle must have been physically located in Florida for 90 nonconsecutive days out of the previous 365 days from the date of the accident. By nonconsecutive days, it means that the insured vehicle could leave Florida and re-enter and still qualify for Florida PIP benefits if the vehicle has been in Florida for longer than 90 days throughout that preceding year.

An insurer is not required to extend the $10,000.00 in Florida PIP benefits to a nonresident insured whose vehicle is not in Florida for longer than 90 nonconsecutive days out of the previous 365 days from the date of the accident.

Most if not all automobile insurance policies have an “Out-of-State Coverage” provision which will detail that insurer’s obligation to comply with a State’s minimum insurance requirements if their nonresident insured becomes subject to the insurance laws of that State. However, some insurance contracts make it the responsibility of the nonresident insured and not the insurer to purchase the required minimum Florida PIP coverage if they plan to stay in Florida for longer than 90-days.

An insurer is not required to extend additional Florida PIP benefits to a nonresident insured that enters Florida and whose insurance policy meets the States minimum PIP or No-Fault requirements.

For Example:

The New York Automobile No-Fault Law requires each insured to carry a minimum of $50,000.00 in No-Fault/ PIP benefits. Thus, if a New York resident drives their vehicle into Florida and is involved in a motor vehicle accident, then they will receive the $50,000.00 in New York PIP benefits as this is greater coverage than the minimum $10,000.00 in PIP benefits which is required under Florida law.

This article is not intended to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that requires attention.

For additional information please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Claims, Personal Injury Protection, PIP/No Fault

Chiropractor’s Challenge To ‘PIP’ Law Kicked Back By Appeals Court

In a 14-page ruling on Wednesday, February 15th, the 3rd District Court of Appeal upheld part of a 2012 overhaul of the state’s personal-injury protection auto insurance system that limits No-Fault (Personal Injury Protection) benefits to $2,500 for individuals who were not diagnosed with an emergency medical condition. The appeals court overturned a judge’s decision in a Miami-Dade County court citing arguments that the 2012 law overhaul was intended to help prevent fraud in the PIP insurance system, but was unconstitutional.

The ruling was in response to chiropractor Eduardo Garrido’s legal victory against Progressive American Insurance Company. Garrido was seeking a determination that the insurer should pay up to the policy limit of $10,000 in the absence of diagnosis that the patient suffered an emergency medical condition as the result of an automobile accident. He also challenged that it was unconstitutional to bar chiropractors from being able to diagnose patients with having suffered an emergency medical condition. The chiropractor treated a patient after an accident in 2013 and submitted invoices to Progressive who only paid $2,500 of the $6,075 billed. According to Progressive, there had been no determination, other than Dr. Garrido’s, a chiropractor, that the patient suffered an emergency medical condition.

Click here to view the full story.

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Filed under FL Legislation, Florida, Insurance, Insurance Claims, Insurance Defense, Miami-Dade County, Personal Injury Protection, PIP/No Fault

Florida Supreme Court Backs Allstate Policy Language in Landmark PIP Case

On January 26, 2017, after months of waiting, those of us in the PIP world finally have our answer to the Allstate policy language debate. It appears that you just need to read the policy as a whole and within its context.

Does Allstate’s PIP policy provide legally sufficient notice to its insureds of its election to use the permissive Medicare fee schedules found in Florida Statute 627.736(5)(a)2 (2009) in order to limit reimbursements for medical services?

The Florida Supreme Court released its opinion on January 26, 2017 holding that Allstate’s PIP insurance policy stating that Allstate’s policy “provides legally sufficient notice of Allstate’s election to use the permissive Medicare Fee Schedule identified in section 627.736(5)(a)2 to limit reimbursements.” Allstate Ins. Co. v. Orthopedic Specialists, No. SC15-2298, at *2, (Fla. 2017).

The case before the Florida Supreme Court involved a certified decision from Florida’s Fourth District Court of Appeals, which had held that Allstate’s policy language did not provide sufficient notice to allow the insurer to apply the Medicare Fee Schedules in limiting reimbursements to bills submitted under the PIP portion of the subject policies. The Fourth District Court of Appeals had certified its decision as it provided a direct conflict with the First District Court of Appeals’ ruling in Allstate Fire & Cas. Ins. v. Stand-Up MRI of Tallahassee, P.A., 188 So. 3d 1 (Fla. 1st DCA 2015), which held that Allstate’s policy language did in fact provide sufficient notice to its insurer’s to allow the Medicare Fee Schedules to be used in limiting reimbursements to bills submitted under the PIP portion of the subject policies. The First District Court of Appeals was not the only Court in the state to opine in favor of Allstate, in fact by the time that the Florida Supreme Court held oral arguments in this matter in August of 2016, the Second and Third District Courts of Appeals had already entered rulings on the issue agreeing with the First District Court of Appeals’ opinion that Allstate had provided sufficient notice to its insureds of its intent to limit PIP reimbursement by using the permissive Medicare fee schedules found in Florida Statute 627.736(5)(a)2 (2009).

The specific portion of Allstate’s policy language which was being evaluated in Orthopedic Specialists v. Allstate Insurance Co., 177 So. 3d 19 (Fla. 4th DCA 2015), states that Allstate will make payments as follows:

“Allstate will pay to or on behalf of the injured person the following benefits:

1. 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.

Id. at 21. An endorsement to the policy provides:

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, as enacted, amended or otherwise continued in the law, including, but not limited to, all fee schedules.

Id. (emphasis and alterations omitted).” Allstate Ins. Co. v. Orthopedic Specialists, No. SC15-2298, at *3, (Fla. 2017)

The Florida Supreme Court found that “[t]he endorsement to Allstate’s policy clearly and unambiguously states that ‘[a]ny amounts payable’ for medical expense reimbursements ‘shall be subject to any and all limitations, authorized by section 627.736, . . . including . . . all fee schedules.’ When read in its context and as a whole with Allstate’s policy, the plain and obvious meaning of the endorsement is that reimbursements will be made in accordance with all of the fee schedule limitations contained within section 627.736(5)(a)2. See, e.g., Stand-Up MRI, 188 So. 3d at 3 (“Virtual Imaging requires no other magic words from Allstate’s policy and its simple notice requirement is satisfied by Allstate’s [unambiguous] language limiting ‘[a]ny amounts payable’ to the fee schedule-based limitations found in the statute.” (second alteration in original); Fla. Wellness & Rehab. v. Allstate Fire & Cas. Ins. Co., 201 So. 3d 169, 173 (Fla. 3d DCA 2016) (“The use of the phrase ‘subject to’ in the policy places the insured on notice of the limitations elected by Allstate; indeed, we cannot discern any other alternative meaning to this language.”); Allstate Indem. Co. v. Markley Chiropractic & Acupuncture, LLC, 41 Fla. L. Weekly D793, 2016 WL 1238533, at *4 (Fla. 2d DCA Mar. 30, 2016) (explaining that “Virtual Imaging did not dictate a form of notice” or require insurers to specifically state the word “Medicare”). Allstate’s policy thus places both providers and insured on notice of Allstate’s election to use the permissive Medicare fee schedules identified in section 627.736(5)(a)2. to limit reimbursements.” Allstate Ins. Co. v. Orthopedic Specialists, No. SC15-2298, at *8-9, (Fla. 2017).

Click here to read the full opinion.

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Filed under Florida Supreme Court, Fourth District Court of Appeals, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP/No Fault

Physicians able to keep practicing for years after they are arrested for pending felony charges

According to the Palm Beach Post, investigators with the Florida Department of Health (DOH) and Broward County Sheriff’s Office arrived at a Pompano Beach pain clinic in 2012 to search for evidence of crime. Dr. Donald Willems, the osteopathic physician admitted to signing blank prescriptions for powerful painkillers such as oxycodone, admitted to letting a clinic manager fill them out, for patients he had not seen.

Eight criminal charges were leveled against Willems, including racketeering and illegally providing oxycodone. With those felony charges still pending, Willems was arrested again on December 21, 2016, named in a federal complaint alleging insurance fraud orchestrated by a local treatment center.

Anyone checking out his background on the Florida Department of Health’s consumer website would never have known it. The site listed the doctors’ license to practice as “clear and active.”

The DOH, which participated in the 2012 clinic raid, did not file formal disciplinary charges against Willems until January 2016, three years after criminal charges were filed.

The Health Department has previously faced criticism for extensive lags between the time a physician is arrested on drug-related charges and the time the state files a disciplinary charge that could result in sanctions, which include revoking a doctor’s license.

In some ways, quick action by the DOH is hindered by law. State law does not require that a doctor tell the department when he or she is arrested; only when there is a conviction. It can be years between an arrest and a trial.

According to DOH spokesman Brad Dalton, when law enforcement agencies tell the state an investigation is underway, “there are times when the department is asked to wait until a criminal case resolves … to protect the confidentiality of an active law enforcement investigation.”

The agency does not impose sanctions. After investigating, it may file a formal disciplinary charge — an administrative complaint — seeking disciplinary sanctions.

The burden of proof needed to justify such disciplinary charges is high, said Dalton. In a civil court suit, lawyers need to prove a “preponderance” of evidence to win their case, he points out. To prove a discipline case against a doctor, the state has to prove “clear and convincing” evidence.

Click here to view the full story.

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Filed under Broward County, DOH, Insurance Claims, Insurance Fraud, Pain Clinics, Palm Beach County

Florida Supreme Court Allstate Fee Schedule Litigation: Shall We Read The Tea Leaves?

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.

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Filed under Auto Insurance Fraud, FL Legislation, Florida, Florida Supreme Court, Fourth District Court of Appeals, Insurance, Insurance Claims, Personal Injury Protection

Andrew v. Matthew: The Evolution of Investigative Tools in Insurance Investigations

I am sure right now many of our insurance carriers are out there running themselves ragged, trying to quickly and efficiently adjust the thousands of claims that are pouring in from Hurricane Matthew.

As the dust settles, I want to remind you of all the great resources and tools you have to investigate and adjust claims that were not available during the time of Hurricane Andrew. Although there are many, the most impactful are cellphones, portable computers and trade-specific tools of laser distance meters, moisture meters and thermal imaging devices.

Clearly, we have come a long way from the time of paper files, pay phones and disposable cameras. During Hurricane Andrew, if you wanted to review a prior claim file, you would need to retrieve it from storage or an archive. If you wanted to make an appointment to inspect the property, you would need to leave messages for the insured at their home or office, and wait for them to call you back at the office. Finally, if you wanted to take pictures of the damage, you would have needed to use a disposable camera (which date back to 1986) and hoped you captured the images you needed.

The most significant technological advancement we have at our fingertips is our cell phones. Cell phones give us the ability to take photographs, take videos, record audio and otherwise document an event. As an example, the first cameras on cell phones arrived in 2000. Since then, cellphones quickly evolved into what we know today. With that in mind, ensure that the insured is asked whether they have any photographs of the property taken prior to your inspection as well as any photographs of the damaged areas prior to them being damaged.

Ask for this information early on in the claim handling, so that if it exists, it can be secured prior to a coverage decision. A photograph is worth a thousand words, and you do not want a few of those words to be “if I’d seen that …. ”

Also, be aware that pursuant to Florida Statute 626.854 (15)(c), which states in pertinent part that an insurer shall not be prevented from “timely conducting an inspection of any part of the insured property for which there is a claim for loss or damage,” you are entitled to inspect all areas claimed as damaged. As such, make sure you are asking to see just that — all damaged areas.

Tools Of The Trade
Advancements specific to the trade have been measuring tools, moisture meters and thermal cameras, to name a few. Although the spring-click tape measure was invented in 1868, it was not until the early 1990s that laser distance measures began to circulate. These electronic tape measures not only provide precise measurements, they also assist in obtaining measurements of hard to reach or unsafe areas, common in many homes after the passing of a major hurricane.

Moisture meters and thermal-imaging devices in their current form are fairly recent concepts that have significantly impacted the trade. These two items, when used together, are very effective in locating sources of leaks, water patterns and extent of moisture. The thermal-imaging device will depict a pattern of temperature differences through contrasting colors, while the moisture meter will indicate whether an item is wet or not and can even provide the percentage of wetness depending on the device.

However, please keep in mind that thermal-imaging devices only measure differences in temperature, and the manufacturers of those devices strongly suggest verifying the thermal readings with moisture meters for that very reason. A change in temperature does not equate to moisture in and of itself.

Finally, the best technological advancement for claims handling has been the portability of the computer, i.e. tablets and laptops. These portable computers were invented in 1981 and provide the ability to retain and organize the information obtained by all of the other advancements mentioned. They also allow you to carry large amounts of information regarding weather conditions, aerial photographs of insured properties and claims history.

Knowledge Base
Ultimately, the one thing that has not changed since Hurricane Andrew is that the insured continues to be your best source of knowledge. Remember that Florida Statute 626.854(15)(b) states in pertinent part that a “person acting on behalf of the insurer” should have “reasonable access at reasonable times to any insured or claimant.”

Use that reasonable access to chat with your insured about the loss while it is still fresh in their mind. Topics of interest should include the specific details of the loss, when the loss was first discovered, efforts at mitigation, and any individuals and companies that have helped with the claim. As to efforts at mitigation, make sure to ask what was done, who did it and how they did. This information will be essential to your handling of the claim to ensure all of the insured’s proceeds are used as efficiently as possible to put the home back to its pre loss condition.

Coupling your best source of knowledge with the information you secure during your claims handling and your grasp of the relevant law will be your recipe for success during the aftermath of Hurricane Matthew.

If you are in need of a quick refresher on the rights and duties included in the applicable statutes, get in touch with registered continuing education instructors who may already have this information in a course approved by the state.

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Filed under Claims Handling, Florida Statute 626.854 (15)(c), Hurricane Andrew, Hurricane Matthew, Insurance, Insurance Claims