Partner Stephen Mellor Wins Summary Judgment for State Farm
Precision Diagnostic (Woodard,
The claimant was involved in a motor vehicle accident in Florida and filed a claim with State Farm under a policy of insurance which was issued by State Farm in Georgia which did not elect for any No-Fault coverage. However, State Farm extended the claimant Florida Personal Injury Protection (PIP) benefits up to $10,000.00 after she qualified for these benefits under Florida law.
Thereafter, the claimant was treated with an MRI provider who rendered two MRI scans to her and submitted a bill to State Farm for $1600.00 for each scan and requested 80% of the billed amount. State Farm reimbursed the MRI provider for each scan at a reduced amount based on 80% of 200% of the Medicare Part B Fee Schedule as listed in the Florida No-Fault Statute. The Plaintiff then filed suit against State Farm for the balance of its charges for these two MRI scans.
Both parties filed Summary Judgment on the issue and Attorney Mellor argued that the Georgia policy language would control how Florida PIP benefits would be reimbursed in this claim even though Florida PIP benefits were extended. Additionally, that said policy language appropriately allowed State Farm to reduce the Plaintiff’s bills at the fee schedules listed in the Florida No-Fault.
Specifically, the Policy provisions at issue defined “Medical Expenses” to mean reasonable expenses for medical services and that “Reasonable Expenses” meant the lowest one of the following charges:
1. The usual and customary fees charged by a majority of healthcare providers who provide similar medical services in the geographical area in which the charges were incurred;
2. The fee specified in any fee schedule;
a. applicable to medical payments coverage, no-fault coverage, or personal injury protection coverage included in motor vehicle liability policies issued in the state where medical services are provided; and
b. as prescribed or authorized by the law of the state where medical services are provided;
3. The fees agreed to by both the insured’s
4. The fees agreed upon between the insured’s
In citing to Florida Wellness & Rehabilitation, et al. v. Allstate Fire and Casualty Ins. Co. et al, 41 Fla. Law Weekly 1619 (Fla. 3d DCA, July 13, 2016) and other Florida Appellate and Supreme Court cases, Attorney Mellor argued that the policy language was clear and unambiguous and put the insured and Plaintiff on notice that if medical services were rendered to her or any other person making a claim under the policy, that State Farm in determining “Reasonable Expenses” could utilize under
The Court agreed with Attorney Mellor’s argument and granted Summary Judgment for State Farm holding that pursuant to the “Reasonable Expenses” policy language that State Farm had appropriately utilized the fee schedules listed in the Florida No-Fault law to reimburse Plaintiff’s bills for the MRI scans at issue and that they were not responsible for any further reimbursement for these services. Moreover, that the Plaintiff has not offered any other reasonable interpretation of State Farm’s Georgia Policy language.