Tag Archives: PIP Claims

Florida’s Third District Court of Appeal Retroactively Applies Allstate PIP Decision

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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Filed under auto insurance, Case Law, FL Legislation, Florida, Insurance, PIP, PIP/No Fault

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.

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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

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.

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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 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

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.”

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

ROIG Lawyers Attorneys Set Precedent in Emergency Medical Condition (EMC) Personal Injury Protection Case

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.

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Filed under Case Law, Florida, Insurance, Personal Injury Protection, PIP/No Fault

Fort Lauderdale residents arrested for PIP Fraud

The Florida Department of Financial Services’ Division of Insurance Fraud announced on March 19, 2015 the arrest of two Fort Lauderdale Residents for PIP fraud following a staged accident. Kendrick Callins and Lashaunda Gibbs were arrested for staging auto accident, patient brokering and personal injury protection insurance fraud.

The Division of Insurance Fraud, Federal Bureau of Investigation, Broward County Sheriff’s office and the Fort Lauderdale Police Department investigation revealed that Callins and Gibbs organized and participated in a staged accident on September 22, 2012, in Fort Lauderdale. The staged accident involved participants, recruited by Callins and Gibbs, who intentionally drove a rented U-Haul truck into a passenger vehicle occupied by arrestees. The arrestees submitted fraudulent insurance claims which were paid by the insurers. Callins and Gibbs each face a maximum sentence of 25 years.

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Filed under Insurance Fraud

The 11th Judicial Circuit Court Issues Key Ruling in Health Care Clinic Licensure Case

On March 10, 2015, the Eleventh Judicial Circuit in and for Miami-Dade County issued a ruling in favor of Imperial Fire & Casualty Insurance in a mandatory licensing (House Bill 119) case. The Court found that the charges submitted for Personal Injury Protection (PIP) benefits to Imperial Fire & Casualty, to be unlawful and thus, noncompensable pursuant to Florida’s Motor Vehicle No-Fault Law.

Imperial Fire & Casualty issued a policy of automobile insurance to the Insured under which the Defendant, Magic Hands Solutions Inc. sought payment. Magic Hands Solutions operated as a medical clinic and allegedly rendered medical treatment to the Insured who was injured in an automobile accident. Subsequently, Magic Hands Solutions submitted charges for payment of PIP benefits to Imperial Fire & Casualty. Magic Hands Solutions was advised that the claim submitted for PIP benefits was not payable because the clinic was not properly licensed pursuant to Section 627.736, Florida Statutes (2013).

In 2012, the Legislature required mandatory licensing for all clinics holding an exempt status, whether by issuance of Certificate of Exemption or self-determined, in order for clinics to receive reimbursement pursuant to the “PIP Statute.” Hence, a clinic must be licensed under Part X, Chapter 400 to receive reimbursement for PIP benefits, unless it qualifies for an exception listed in Section 627.736(5)(h).

The Court found that the Magic Hands Solutions being wholly owned by a license massage therapist does not qualify for any of the exceptions delineated in §627.736(5)(h)(1)-(6) and was required to obtain a Health Care Clinic license as a condition precedent to receiving reimbursement of PIP benefits.

As a result of Magic Hands Solutions’ failure to obtain a Health Care Clinic License, the Court found that the charges submitted were unlawful and thus, noncompensable pursuant to Florida’s Motor Vehicle No-Fault Law and that Imperial Fire & Casualty.

Imperial Fire & Casualty Insurance Company vs. Magic Hands Solution Inc., Case No. 2014-2211 CC 24 (01) (Fla. 11th Circuit March 10, 2015).

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Filed under Fla. Stat. 627.736 (2008)