The Pinellas County Court ruled in favor of Direct General Insurance in two recent PIP cases heard in the Small Claims Division.
In both cases, the plaintiff alleged breach of contract for failure to pay 80% of reasonable and necessary medical expenses. Direct General responded with a Motion for Summary Judgment, claiming that it paid the medical expenses in accordance with the policy language.
The policy in question stipulated that the insurer will pay 80% of qualifying expenses. The court noted the presence of additional policy language that clearly stated the potential for further reductions in reimbursement, as follows:
“… in determining whether charges for medical expenses under this Part are reasonable, we may reduce payments for amounts that are billed to any lesser amount that results from the application of any schedule of charges or alternative reimbursement method that is expressly reference or authorized for use by the insurers under the No Fault Law.”
The court determined that Fla. Statute §627.736(5)(a)2 is the governing clause, even if it may not have been specifically referenced. The court cited Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So. 3d 63, 68 (Fla. 4th DCA 2011) in its decision.
The cases are Wood Health, Inc. vs. Direct General Insurance (Ref. 12-4904SC-SPC), and Spinal Corrections Centers vs. Direct General Insurance (Ref. 12-49088SC-SPC). Click on the case titles to view the court documents.