Category Archives: Insurance Defense

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).

Comments Off on Geico Sues Florida Health Clinic for ‘Unnecessary’ Massage Claims

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

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

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

Filed under auto insurance, Claims Handling, Florida, Insurance, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP, 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.

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

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.

Comments Off on Florida Supreme Court Backs Allstate Policy Language in Landmark PIP Case

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

Federal Agents Arrest Participants in Medical Fraud Ring

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.”

Click here to view the full story.

Comments Off on Federal Agents Arrest Participants in Medical Fraud Ring

Filed under Florida, Insurance, Insurance Defense, Insurance Fraud

GEICO Wins Sanctions Against Law Firm, Auto Repair Shop

GEICO won a sanctions request in Florida federal court against a Mississippi auto repair shop and its law firm. U.S. Senior District Judge Gregory A. Presnell ruled that GEICO’s Motion for Attorney Fees was “meritorious” and ordered the insurance company to prepare a specific fees request.

Clinton Body Shop and its law firm, John Arthur Eaves Attorneys, lost a summary judgment in a related suit charging GEICO with unjust enrichment and tortious interference with business relations. GEICO said that the summary judgment victory in that previous case barred the body shop from reasserting those same claims. The federal judge in the Middle District of Florida agreed.

“Any reasonable attorney or claimant would have known what is one of the most fundamental principles of our legal system: that a claim or issue, once litigated to a final adjudication, cannot be relitigated,” GEICO said in its motion. “(R)efiling of the same claims they lost to GEICO three months earlier in another case is automatically bad faith, warranting sanctions.”

Clinton’s argument was that the two suits involved separate entities: the first against GEICO Insurance Co., the latter against GEICO General Insurance.

The case is part of multidistrict litigation in which repair shops in 10 states are accusing several insurance companies of violating the Sherman Antitrust Act by colluding to keep reimbursement rates low for auto body repair work.

Presnell had dismissed Clinton’s claims against GEICO in May before granting sanctions on July 19.

Click here for full story (registration required).

Comments Off on GEICO Wins Sanctions Against Law Firm, Auto Repair Shop

Filed under Florida, Insurance, Insurance Defense, Middle District of Florida

Another DCA Sides With Insurers on Fee Schedule Language

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.”

Click here for full story.

Comments Off on Another DCA Sides With Insurers on Fee Schedule Language

Filed under Fla. Stat. 627.736 (2012), Florida, Insurance, Insurance Defense, Miami-Dade County, Personal Injury Protection, PIP/No Fault

Federal Appeals Court Reinstates PIP Claims Suit Against HCA

A federal appeals court has revived a lawsuit against HCA Holdings charging that HCA and three of its Florida hospitals violated Florida’s Deceptive and Unfair Practices Act.

The U.S. Court of Appeals for the Eleventh Circuit’s April 26 ruling overturned a February 2015 federal court decision in the Middle District of Florida that dismissed the class action. That suit accused three HCA hospitals—Memorial Hospital Jacksonville, North Florida Regional Medical Center of Gainesville and JFK Medical Center in Atlantis—of charging unreasonably high fees for emergency radiological services covered by Florida’s Personal Injury Protection (PIP) insurance.

The four Florida residents who filed the complaint received emergency radiological services after motor vehicle accidents. They said they were billed more than other patients who received the same services. “In fact, these fees are up to 65 times higher than the usual and customary fees charged to non-PIP patients for similar radiological services,” according to the complaint.

In one example, the court’s opinion said the hospitals charged between $5,900 and $6,965 for spinal CT scans on the plaintiffs. The ruling said Medicare rates for spinal CT scans are between $213 and $220, and rates for uninsured patients go up to $3,454.

The complaint said the exorbitant rates caused the residents’ $10,000 PIP coverage to be exhausted prematurely. The complaint also accuses HCA of breach of contract as the four Floridians entered into a Condition of Admission contract that required their accounts to be paid at the hospitals’ price lists. All four plaintiffs said they weren’t provided such a price list at the time of their treatments.

Only one of the four plaintiffs was allowed to go forward with a suit against a single hospital in the 2015 ruling by U.S. District Judge James Moody in the Middle District of Florida. Moody’s ruling was overturned by a unanimous Eleventh Circuit panel consisting of Judges Beverly B. Martin, Julie E. Carnes and Senior Judge R. Lanier Anderson III. The suit was originally filed July 2014 in the Southern District of Florida.

 

Comments Off on Federal Appeals Court Reinstates PIP Claims Suit Against HCA

Filed under HCA, Health care, Insurance, Insurance Defense, Insurance Fraud, Middle District of Florida, Personal Injury Protection, PIP/No Fault

Pinellas County Court on Application of Deductible

In Bayfront Health Education & Research Organization Inc. v. Progressive American Insurance Co., the Plaintiff billed the Defendant for services. The Defendant reduced the bills, subtracted the insured’s deductible, and paid eighty percent of the difference. Under Florida Statute § 627.736, the Defendant pled that only reasonable, related, and necessary “medical expenses are reimbursable and likewise applicable to any deductible.” The Plaintiff moved for summary judgment claiming that the Defendant misapplied the deductible. The Plaintiff claimed that the deductible should be applied to the amount billed.

The Court held that Florida Statute § 627.739(2) “requires the deductible be applied to 100 percent of the reasonable expenses.”

The Court construed Florida Statute § 627.739(2) and Florida Statute § 627.736. Under Florida Statute § 627.739(2), “[t]he deductible amount must be applied to 100 percent of the expenses and losses described in s. 627.736.” The Court looked to Florida Statute § 627.736 “to determine the expenses and losses described.” The Court said that Florida Statute § 627.736 “describes the payable expenses as ‘reasonable expenses.’”

The Court also found that “the deductible is applied to 100% of all reasonable expenses” under the insurance contract.

The Court interpreted the insurance contract. Under the insurance contract, “the deductible will be applied to 100% of the expenses and losses covered under Personal Injury Protection Coverage.” The Court said that “[m]edical benefits are part of the Personal Injury Protection Coverage and defined as 80% of all reasonable expenses.”

In sum, under Florida Statute § 627.739(2), Florida Statute § 627.736, and the insurance contract, the Court held that “the deductible is applied to 100% of the provider’s reasonable expenses.”

Order Denying Plaintiff’s Motion for Summary Judgment, in Part, and Granting, in Part, Bayfront Health Educ. & Research Org. Inc. v. Progressive Am. Ins. Co., No. 12-5556-SC (Fla. Pinellas Cty. Ct. 2015).

Comments Off on Pinellas County Court on Application of Deductible

Filed under Fla. Stat. 627.736 (2012), FLA. Stat. 627.739(2), Florida, Insurance, Insurance Defense

The Florida Medical Association Files Brief Against Allstate

The Florida Medical Association (FMA) will be permitted to file a friend-of-the-court brief in a case before the Florida Supreme Court over fees paid to medical providers who treat injured victims of vehicle wrecks.

Allstate Insurance had asked Florida’s justices to reject the FMA motion to file a friend-of-the-court brief, but the Supreme Court ruled on March 30 in FMA’s favor, according to the News Service of Florida.

Allstate is appealing a ruling by the Fourth District Court of Appeal concerning Florida’s PIP auto insurance system. A key issue in the ruling—which involved 32 consolidated cases—focused on whether policies were clear that Allstate would make payments to providers based on a Medicare fee schedule.

“This case is important to the FMA because it involves the application of a statute that deals with reimbursement rates for FMA member physicians who provide treatment to patients with personal injury protection insurance,” FMA said in its March 11 motion.

A Fourth DCA panel agreed with providers that insurance policies were ambiguous on whether payments should be based on the Medicare fee schedule, which places limits on payment amounts.

“Allstate is attempting to use a payment methodology that will dramatically limit or reduce the standard and customary rate of reimbursement for treatment and services for FMA members,” the FMA said in its motion. “FMA physicians have seen or will see a dramatic reduction in reimbursement rates under the PIP law based on the ruling in this case.”

Click here to view full article.

Comments Off on The Florida Medical Association Files Brief Against Allstate

Filed under Florida Medical Association, Health care, Insurance Defense, Personal Injury Protection, PIP/No Fault