Tag Archives: PIP insurance

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

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

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.

 

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

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

Florida Insurance Commissioner Kevin McCarty resigns

On January 5, 2016, Kevin McCarty resigned as Florida’s top insurance regulator and stated that his departure would be effective May 2, 2016, according to Bradenton Herald. McCarty, 56, is the state’s Insurance Commissioner who decides how much homeowners pay for their property insurance.  He was appointed to the position in 2003 by Governor Jeb Bush and has served under the leadership of three Governors since then. Under Bush tenure, McCarty helped navigate the state through a series of devastating hurricanes while seeking to protect elderly consumers from fraudulent merchants of insurance products.

After many years of navigating the capital’s perilous political landscape McCarty was viewed as vulnerable after Governor Rick Scott took the oath as governor for the second time. Scott’s office already had a replacement in mind: Ron Henderson, a Louisiana insurance official who was being promoted by Fred Karlinsky, a Tallahassee Lobbyist for insurance interests and Scott supporter. Consumer groups rallied to McCarty’s side as a result of the controversy following Scott’s removal of Gerald Bailey as the state’s top law enforcement official.

McCarty is the state’s first appointed insurance commissioner and director of the state Office of Insurance Regulation. His successor must win the support of both Scott and Jeff Atwater, Chief Financial Officer, in a vote by the Governor and Cabinet.

McCarty’s departure leaves an empty position, one of the most challenging jobs in state government due to the sensitivity surrounding the cost and availability of insurance in a state vulnerable to hurricanes and insurance fraud.

Click here to read article.

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Filed under Florida, Insurance, Insurance Fraud

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

Cape Coral Cracks Down on Drivers without Insurance

Representatives from the National Insurance Crime Bureau (NICB), the local police department, and 17 state and national auto insurance carriers conducted an insurance crackdown in Cape Coral, Fla. on Tuesday, March 17. More than 35 police officers split into three groups, all on the lookout for uninsured motorists and motorists with fraudulent insurance.

The officers pulled over speeders and drivers not wearing their seatbelts, and then checked whether they had valid proof of insurance in hand. Drivers who were stopped for speeding or being unbuckled, but had valid paperwork available, could be let go with a warning. At the end of the day, officers had given out 230 written warnings and 68 uniform traffic citations, 15 of which were for no proof of insurance.

“We try to do an operation like this at least once a year,” Cape Coral Police Department spokesman Sgt. Dana Coston said. While the officers pulled over drivers, the NICB and dozens of insurance representatives were back at the police station, working directly with the officers to verify coverage.

A common scheme, Sgt. Coston explained, is for an individual to apply for auto coverage, get the paperwork, cancel the insurance, and then use the now-invalid insurance card as proof of coverage. Officers usually have to rely on state data, which is often outdated, to verify coverage, but because officers had “real time” access to insurance representatives on Tuesday, they could confirm on the spot if the insurance coverage was valid.

Sgt. Coston was heartened by the results of the day’s work. “Seeing that [only] about 5 percent of the drivers had any type of problem when stopped today is very encouraging. That’s probably one of the highest rates of compliance we’ve seen in years.”

Coston went on to explain that, because it is likely that at least some of those ticketed will show up in court with their missing paperwork, “the rate of compliance is actually even higher than the 95 percent we saw today.”

As for those who continue to drive without insurance or with fraudulent insurance? “They’ll get caught eventually, it’s just kind of rolling the dice,” said Cape Coral Police Sergeant Jon Kulko.

Cape Coral, Fla. is located on the Gulf Coast in Lee County, just south of Fort Myers.

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Filed under Insurance Fraud

1st DCA Upholds Allstate Use of Medical Fee Schedules

In an opinion filed March 18, 2015, Florida’s First District Court of Appeal held that language in an Allstate Insurance Co. policy gave sufficient notice to an assignee of its election to use Medicare fee schedules to limit benefit reimbursements under a PIP policy. Stand-Up MRI of Tallahassee, an assignee of 14 named insureds, sued Allstate in county court, contending that Allstate’s alleged failure to give adequate notice was contrary to the Florida Supreme Court’s decision in Geico v. Virtual Imaging. The trial court agreed with Stand-Up MRI and certified a question of great public importance to the Appellate Court.

In Virtual Imaging, as here, an MRI provider had supplied services and then disputed the insurer’s authority to limit reimbursements under Medicare fee schedules. Pursuant to the Florida PIP statute, automobile insurers are required to provide PIP coverage for 80 percent of all “reasonable expenses” for medically necessary services.

The dispute here centers on whether Allstate’s policy language provided adequate notice of its election to limit reimbursements via the Medicare fee schedules or if, as Stand-Up MRI contends, the policy fails because it is ambiguous. Allstate points to the following language in the policy as having satisfied the Virtual Imaging notice requirement:

In accordance with the Florida Motor Vehicle No-Fault Law, [Allstate] will pay to or on behalf of the injured person the following benefits. . . .

Medical Expenses

Eighty percent of reasonable expenses for medically necessary … services. …

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.

The appellate court agreed with Allstate, concluding that the policy gives sufficient notice of its election to limit reimbursements by use of the fee schedules. In making its decision, the court pointed to language in the policy stating that reimbursements “shall” be subject to the limitations of §627.736, including “all fee schedules.”

Section 627.736(5)(a) 2 refers to Medicare fee schedule-based limitations and provides that insurers “may limit reimbursement to 80 percent of the … schedule of maximum charges.” Thus, concluded the court, the notice requirement was satisfied by Allstate’s language limiting “any amounts payable” to the fee schedule-based limitations found in the statute.

Furthermore, the court also distinguished the language in Allstate’s policy from that found deficient in Virtual Imaging. There, the Florida Supreme Court concluded that Geico’s policy failed to “indicate in any way” that it intended to limit its reimbursement amounts using the fee schedules. Here, Allstate’s policy expressly limits reimbursements by “all fee schedules” in the statute, satisfying the Virtual Imaging notice requirement.

Stand-Up MRI also contended that Allstate’s use of the phrase “subject to . . . all fee schedules” fails to provide sufficient notice that reimbursements will always be limited by the fee schedules, arguing that “subject to” means only that Allstate had the option to limit reimbursements per the Medicare fee schedule , not that it would so limit reimbursements. The court, however, found no such ambiguity, stating that the language of the policy makes reimbursements subordinate to the fee schedule in “rather unmistakable terms.”

In sum, the court concluded that Allstate’s policy language gave legally sufficient notice to its insureds of its election to use the Medicare fee schedules as required by Virtual Imaging. The trial court’s decision was reversed and the case remanded for further proceedings.

The cases cited are listed below for reference.

Allstate Fire and Casualty Ins. v. Stand-Up MRI of Tallahassee, Case No. 1D14-1213, et al., 1st DCA Fla. (March 18, 2015).

Geico Gen. Ins. Co. v. Virtual Imaging Servs. Inc., 141 So. 3d 147 (Fla. 2013).

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Filed under Fla. Stat. 627.736 (2012), The Statutory "Fee Schedules"