Tag Archives: PIP insurance

Understanding Florida Letters of Protection (LOP)

Many times after people are involved in automobile accidents and they do not have health insurance, medical providers will agree to continue to treat them with the anticipation that should the patient recover any money from a lawsuit settlement or judgment, the provider will be paid from those proceeds. This type of agreement is called a Letter of Protection, sometimes called a LOP.  A letter of protection is a letter that is sent by an attorney on behalf of a client to a medical provider. The letter is an agreement between the patient/client and the medical provider. In this agreement, the medical provider will agree to provide medical treatment to the patient in lieu of receiving payment for services until proceeds from a settlement or a jury award are received. Should the patients not receive a favorable recovery, the patient may remain liable to pay for the medical services rendered. The LOP operates as a contract between the patient and the medical provider, which operates as a lien on any injury settlement.

LOP’s are typically utilized in Florida as a result of the fact that Florida PIP insurance pays 80% of the accident-related medical bills, which leaves 20% of the medical bill outstanding. Without a LOP, a medical provider may require upfront payment or refuse to provide treatment without additional assurances that it will be paid. In addition, LOP’s may be deemed necessary in cases where the medical bills exceed $10,000 and the patient lacks health insurance or other sources of available payment.

However, these LOP’s prevent a jury from accurately evaluating bodily injury claims. For example, when a person has health insurance, the amount charged by the medical providers are typically highly regulated and controlled. When a patient treats under a LOP, these regulations and controls do not exist. As a result, plaintiffs in litigation often incur larger bills in an effort to drive up the overall value of the economic damages in their case. In turn, medical providers operating under LOP’s often charge vastly different amounts than they typically would in the treatment of patients with health insurance, which the bills are being submitted through the patient’s health insurance coverage.

After recovery in personal injury suits, the plaintiff’s attorney may further negotiate the amounts payable to the medical providers. As a result, the plaintiff’s counsel utilizes these high medical charges as “evidence” of damages in their case whereby both the plaintiff’s counsel and medical providers are fully aware that the amounts billed will be drastically reduced and paid following any recovery. As a result, the court is provided with inaccurate information for which the jury to determine actual damages. Often these plaintiff attorneys and medical providers have ongoing business relationships. Each is making referrals to the other with the anticipation of payment for services ultimately occurring at the end of any claim or case. Uncovering information concerning this ongoing business relationship between the attorneys and the medical providers has proven difficult in recent years.

In Worley v. Central Florida Young Men’s Christian, Etc. (2015)163 So. 3d 1240, the Florida Fifth District Court of Appeals addresses the issue of whether during legal proceedings, the plaintiff was required to produce information pertaining to the relationship between the patients treating physicians and her attorney. The court held that a referral of a client by an attorney to a healthcare provider is protected by attorney-client privilege. In April 2017, the Florida Supreme Court reviewed this Fifth District Court of Appeals decision and found that whether the attorney-client privilege protects a party from being required to disclose that his or her attorney referred the party to a physician for treatment implicates confidential communication between the attorney and the client and is therefore protected. This issue is sure to receive additional judicial scrutiny in the future.

To understand how letters of protection are utilized it is also important to understand how the collateral source rule works in Florida. Following a jury verdict, a trial court must reduce jury awards for medical damages by the amount that is being paid for the benefit of the claimant, or which are otherwise available to the claimant from all collateral sources. Meaning that if the plaintiff’s medical expenses incurred following an injury were covered by other available insurance, the damage award should be reduced by the amount paid by the collateral source. This rule was created in an attempt to reduce insurance costs and prevent windfall judgments. Although the set-off must occur, the payments from the collateral source benefit are not admissible at trial. It is thought that allowing such evidence would confuse the jury as to liability and damages.

Typically, contractual discounts fit within the statutory definition of collateral sources.[1] Therefore, where a medical provider bills for services at one amount but negotiates with an insurer for the payment of a decreased amount, the negotiated decreased amount is the amount used for the set-off. In Gobel, the hospital charged $574,554.31. However, due to pre-existing fee schedules between the medical provider and what the health insurer paid, and the hospital accepted less, $145,970.76. This difference between what was billed and the amount accepted shows how the amount charged is not always related to the amount of medical provider expects to receive payment or will accept in full payment for the medical services

In Florida, the Collateral Source Rule forbids negligent parties from paying less in damages simply because a third party has already compensated the injured person. As such, under the collateral source rule, health insurance payments and other sources of compensation do not affect the defendant’s liability. Generally, courts do not admit evidence of any plaintiff’s health insurance to allow the plaintiff to recover the full extent of the plaintiff’s damages.

Florida Statute 768.76(2) (a) defines Collateral Sources as “payments made to the claimant.” Therefore, letters of protection, which merely deferred payment until after settlement/judgment, the amount negotiated in a letter of protection is not considered a collateral source and are therefore not subject to collateral source reductions post-judgment.

Understanding letters of protection and how they are utilized many times in litigation will help understand how the “business” of personal injury litigation occurs. This will allow for a better understanding of how medical charges can be manipulated and utilized at trial in an attempt to increase settlements and judgments by plaintiff attorneys.

[1] Joerg v. State Farm, 176 So. 3d 1247, 1249 (Fla. 2015) citing Gobel v Froham, 901 So. 2d 830, 833 (Fla. 2001)

 

Filed under Personal Injury Protection (PIP)

Possible Changes to Florida Damages Statute: Florida Statute 768.042 in Personal Injury Cases

Jurys often time struggle with calculating future medical expenses to award or not to award during jury deliberations. Florida law restricts recovery of future medical expenses to those expenses “reasonably certain” to be incurred. [1] At trial, a jury must be offered evidence which reasonably supports that future medical services are reasonably certain to occur. Awarding damages for future medical expenses cannot be grounded on the mere possibility that certain treatment might be obtained in the future. [2]

Further, a jury must be provided evidence that is reasonably certain to allow a jury to determine the amount of those expenses. In proving special [past] medical damages for personal injuries, proof should be offered (1) that the medical services were rendered, (2) what the reasonable charges are therefor, (3) that the services for which they were rendered were necessary, and (4) that they were related to the trauma suffered in the accident. Florida law restricts recovery of future medical expenses to those expenses “reasonably certain” to be incurred. [3] At trial, a jury must be offered evidence which reasonably supports that future medical services are reasonably certain to occur. Awarding damages for future medical expenses cannot be grounded on the mere possibility that certain treatment might be obtained in the future. [4]

Florida Standard Jury Instruction 501.2(b) provides the basis of how a jury is to award damages for medical expenses. Specifically, Florida Standard Jury Instruction 501.2(b) states:

b. Medical expenses:

Care and treatment of claimant:

The reasonable [value] [or] [expense] of [hospitalization and] medical [in nursing] care and treatment necessarily or reasonably obtained by (claimant) in the past [or to be so obtained in the future].

Recently, House Bill 9/Senate Bill 1668 was offered to require certain medical expenses in personal injury claims be based on certain usual & customary amounts received. Should this bill become law, a jury will be allowed to rely upon usual and customary charges as evidence to be utilized as a way to calculate past, present, or future medical expenses. Currently, Florida Statute 768.042 states:

768.042 Damages-

(1) In any action brought in the Circuit Court to recover damages for personal injury or wrongful death, the amount of general damages shall not be stated in the complaint, but the amount of special damages, if any, may be specifically pleaded and the requisite jurisdictional amount established for filing in any court of competent jurisdiction.

However, should House Bill 9/Senate Bill 1668 become law, the following will be added as subsection 2 to Florida Statute 768.042:

(2) In any claim for damages related to personal injury to the claimant, evidence regarding the past, present, or future medical expenses must be based on the usual and customary charges of the community where the medical expenses are or are reasonably probable to be, incurred. With respect to past and present medical expenses, if the claimant is entitled to be reimbursed to any public or private health insurance or governmental health coverage, the amounts paid or payable under the insurance or governmental health coverage shall be presumed to be the usual and customary medical charges, unless the claimant shows that such amounts are inadequate under the circumstances. With respect to damages for future medical expenses, evidence of the availability of private or public health insurance coverage may be considered along with other relevant evidence. Usual and customary charges may not include increased or additional charges based on the outcome of the litigation.

As outlined in the January 28, 2020 Bill Analysis and Fiscal Impact Statement concerning Senate Bill 1668, this bill would require that in any claim for damages for personal injury to a claimant, evidence of past, present, or future medical expenses would have to be based on the usual and customary charges in the community where the medical expenses were incurred.

Currently, jury’s rely upon evidence of past expenses and testimony from experts as to reasonably certain procedures which are alleged needed as evidence of what future medical expenses it should award. This proposed new methodology of calculating future medical expenses is consistent with the current Florida methodology for calculating PIP reimbursement under Florida No-Fault Law, which also requires a determination of costs based on usual and customary charges in the community. This bill would prevent utilization of evidence of cost which had been inflated in anticipation of the jury award that may be larger than the amount insurers are typically willing to pay and larger than amounts healthcare providers typically accept. As a result, this will decrease the opportunity for plaintiffs to present evidence of inflated costs through the use of a letter of protection.

[1]Loftin v. Wilson, 67 So. 2d 185,188 (Fla 1953)

[2] White v. Westlund, 624 So. 2d 185, 188 (Fla. 4th DCA 1993)

[3] Loftin v. Wilson, 67 So. 2d 185,188 (Fla 1953)

[4] White v. Westlund, 624 So. 2d 185, 188 (Fla. 4th DCA 1993). Crowe v. Overland Hauling, Inc., 245 So. 2d 654, 656 (Fla. 4th DCA 1971) (quoting Ratay v. Yu Chen Liu, 260 A. 2d 484, 486 (Pa. Superior, 1969).

Filed under Legislation, Personal Injury Protection (PIP)

Florida Doctor Arrested for Allegedly Defrauding Nine Auto Insurers

According to a statement from the Florida Department of Financial Services, Dr. Celestino Santi was arrested for allegedly defrauding nine auto insurance companies our of more than $500,000 in unlicensed medical billing.

Investigators reveal that Santi was allegedly acting as a “straw owner” of Accident Care Center of Boggy Creek to disguise the identity of the unlicensed, true owner of the motor vehicle accident medical treatment center.

Click here to read the article.

Filed under Fraud, Personal Injury Protection (PIP)

Roig Lawyers Complimentary Webinar – Injections Don’t Need To Be Painful

Injections SM - 5

We are pleased to announce a webinar perfect for October, “Injections Don’t Have to be Painful” presented by Orlando Managing Partner Scharome Wolfe. The webinar will take place on Tuesday, October 29th at 1:00 pm. This course explores the use of injections by pain management physicians and their teams.

This CE is approved for 1 credit for Florida adjusters.

REGISTER NOW!

Filed under Firm News

How Billing Processes of Florida Medical Providers for PIP Claims are Affected by the Thirty Third Amendment to Regulation 83 Under New York-Based Insurance Policies

The New York State Department of Financial Services (“DFS’) has finalized the Thirty-Third Amendment to Regulation 83 (the “33rd Amendment”), which was published in the State Register on October 25, 2017 and will affect treatment rendered on or after January 23, 2018. Pursuant to the accompanying press release, the 33rd Amendment is designed to “limit the amount that insurers can reimburse for healthcare services performed outside of New York State under its no-fault insurance law.”[1] By limiting reimbursement amounts for out-of-state no-fault healthcare services, which are treating New York State (“NYS”) residents, the DFS intends to “curb costs and abuses” by out-of-state medical providers charging excessive rates.[2].

Regulation 83, governing the reimbursement of out-of-state providers, previously provided that:

“If a professional health service is performed outside New York State, the permissible charge for such service shall be the prevailing fee in the geographic location of the provider.” (11 NYCRR § 68.6).

The case of Surgicare Surgical Assoc. v National Interstate Ins. Co., 2014 WL 6610048, 2014 N.Y. Slip Op. 24362) (Anthony Cannataro, J.), provides a good example of an out-of-state provider seeking reimbursement at an exorbitant rate, diminishing the coverage available to the insured for other medically necessary services. There, the provider performed arthroscopic surgery on a covered person in New Jersey and submitted a claim for reimbursement under the applicable New York No-fault policy. Although the state of New Jersey has a fee schedule that applies to the reimbursement of medical services under the New Jersey’s No-fault law, the provider submitted a bill to the insurer for approximately $5,000 more than the amount it would have been reimbursed had the claim involved a New Jersey auto policy and as a result, was governed by the New Jersey fee schedule. The insurer reimbursed the amount permitted under the New Jersey fee schedule, essentially maintaining that, pursuant to Regulation 83, the New Jersey fee scheduled reflected the permissible amount in the geographic area. The provider sued for the difference. After discussing the applicable regulations and policy considerations behind the enactment of the New York No-fault law, including the legislative intent of cost containment, a New York City Civil Court judge held that, “when services are rendered outside of New York but in a jurisdiction which utilizes a fee schedule, the insurer complies with Section 68.6 by paying the ‘permissible’ charge for that particular medical service, that is, the amount permitted by that jurisdiction’s fee schedule.” The provider appealed and the Appellate Term affirmed. See Surgicare Surgical Assoc. v National Interstate Ins. Co., 2015 NY Slip Op 25338 (App. Term 1st Dept. 2015).

In other instances, the amount sought by out-of-state providers has been tens of thousands of dollars above the amount that would be permitted under the New York Fee Schedule. Recognizing the potential for fraud and abuse, the Amendment provides an effective solution to the exploitation of the No-fault system by out-of-state providers and, adopts, to some extent, the holding in Surgicare and, by regulation, strengthens the limits placed on reimbursement of such providers. Specifically, the Amendment states:

11 NYCRR 68.6: Health services performed outside New York State

(a)(1) If a professional health service reimbursable under [section 5102(a)(1) of the] Insurance Law section 5102(a)(1) is performed outside this State, the amount that the insurer shall reimburse for the service shall be the lower of the amount charged by the provider and the prevailing fee in the geographic location of the provider with respect to services:

(i) that constitute emergency care;

(ii) provided to an eligible injured person that is not a resident of this State; or

(iii) provided to an eligible injured person that is a resident of this State who, at the time of treatment, is residing in the jurisdiction where the treatment is being rendered for reasons unrelated to the treatment.

(2) For purposes of this subdivision, emergency care means all medically necessary treatment initiated within 48 hours of a motor vehicle accident for a traumatic injury or a medical condition resulting from the accident, which injury or condition manifests itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part.  Medically necessary treatment shall include immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care.  Emergency care extends during the period of initial hospitalization until the patient is discharged from the hospital.

(b) Except as provided in subdivision (a) of this section, if a professional health service reimbursable under Insurance Law section 5102(a)(1) is performed outside this State with respect to an eligible injured person that is a resident of this State, the amount that the insurer shall reimburse for the service shall be the lowest of:

(1) the amount of the fee set forth in the region of this State that has the highest applicable amount in the fee schedule for that service;

(2) the amount charged by the provider; and

(3) the prevailing fee in the geographic location of the provider.

(c) If the jurisdiction in which the treatment is being rendered has established a fee schedule for reimbursing health services rendered in connection with claims for motor vehicle-related injuries and the fee schedule applies to the service being provided, the prevailing fee amount specified in subdivisions (a) and (b) of this section shall be the amount prescribed in that jurisdiction’s fee schedule for the respective service.

The 33rd Amendment separates treatment by out-of-state medical providers into the following two categories:

  1. Out-of-state medical services, which (a) constitute emergency care[3], (b) are provided to non-NYS residents, and (c) are provided to patients with a NYS domicile, who are currently living in the state where the treatment is being rendered, for reasons unrelated to the accident.
  2. Out-of-state medical services provided to a NYS resident, currently living in NYS.

There is one main difference between the two categories – which State’s no-fault fee schedule governs and must be utilized by the insurer when reimbursing the medical provider. Simply put, if the medical services fall into Category 1, the medical provider’s reimbursement will be capped at the No-Fault Schedule rate for the State and region wherein the services are provided. By contrast, if the medical services fall into Category 2, the medical provider’s reimbursement will be capped at the highest rate available under the New York State No-Fault Fee Schedule unless the State where the treatment is being rendered has an established fee schedule for claims related to motor vehicle-related injuries.

As such, section (c) of 11 NYCRR 68.6 would apply to medical services rendered in Florida as there is an established set of fee schedules within the Florida No-Fault Law. While the foregoing may be the general rule, there are nuances requiring attention.

The reimbursement rate for medical services is now capped at the prevailing fee in the geographical location of the provider unless the provider charges less. Thus, the 33rd Amendment now limits the prevailing geographical rate to that area’s local No-Fault Fee Schedule Rate. In other words, if x-ray services are performed in Miami, Florida the provider’s reimbursement is limited to the schedule of maximum charges as listed in the Florida No-Fault law for that geographical region (Miami) (i.e, 200% of Medicare Part B).

The medical providers and insurers also need to be familiar with the amendment’s definition of what constitutes “emergency care”’ and how it relates to reimbursement.

Example 1: If a person is transported to the Hospital as a result of a motor vehicle accident in Florida and that person lives in Florida but is covered by a New York policy, then that Hospital provider’s charges would be limited to 75% of the usual and customary charge pursuant to the Florida No-Fault Law’s schedule of maximum charges. Moreover, the emergency services doctor would be paid at its usual and customary charge which is generally the submitted charge.

Example 2: Compare to the facts that this same individual is involved in a motor vehicle accident in Florida on January 1, 2019 and is not transported to the Hospital. However, three days later they decide to go to the emergency room due to having neck and back pain related to the accident. Would these Hospital and physician services now be considered “emergency care”?  Under this amendment, it would not because the treatment was not initiated within 48 hours following the accident.

Now further compare these facts with the applicable schedule of maximum charges under Florida Statute §627.736(5) (2018) which states in pertinent part:

The insurer may limit reimbursement to 80 percent of the following schedule of maximum charges:

a. For emergency transport and treatment by providers licensed under chapter 401, 200 percent of Medicare.

b. For emergency services and care provided by a hospital licensed under chapter 395, 75 percent of the hospital’s usual and customary charges.

c. For emergency services and care as defined by s. 395.002 provided in a facility licensed under chapter 395 rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community.

d. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services.

e. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.

In the situation listed in Example 2, the patient’s condition would not be considered “emergency care” and thus, payment would be made at 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services or 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.

Conclusion

In order to maximize recovery without running afoul of the new fee schedule mandates of the 33rd Amendment, Florida medical providers treating patients covered by New York No-Fault policies must be cognizant of whether the service rendered meets the definition of “emergency care.” What this amendment does clarify is that if medical services are rendered in Florida under a PIP claim brought under a New York policy, then the maximum amount to be paid to the medical providers for these services would be limited to Florida’s schedule of maximum charges.

[1] Press Release, posted October 10, 2017, http://www.dfs.ny.gov/about/press/pr1710101.htm

[2] Id.

[3] Under the 33rd Amendment, in order to constitute emergency care, the treatment must be initiated within 48 hours of the motor vehicle accident.

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 require 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. 

Filed under Personal Injury Protection (PIP)

Pending PIP Litigation on the East and West Coasts Could Impact States In Between

PropertyCasualty360 published a report about pending automobile personal-injury litigation in California and New York that could have a lasting impact if the decisions spread to other jurisdictions. Courts will determine allowable evidence for suits involving these insurance claims.

East Coast

In New York, insurers investigated radiologist Andrew Carothers, a suspected illegal straw owner after he filed 20,000 lawsuits against auto-insurance carriers. After insurers refused to pay Carothers, he flooded the state’s courts with more than 20,000 lawsuits seeking collection for unpaid “services.” The civil cases were consolidated, and the jury agreed Carothers was fraudulently engaged in the corporate practice of medicine. The Appellate Division affirmed, so Carothers went to the New York Court of Appeals, where the case awaits a decision.

A favorable decision can deter scams like Carothers’ in other states that forbid the corporate practice of medicine. Fraudsters who often quickly expand operations to line their pockets in other states could be deterred. A decision is expected in 2019.

West Coast

Dave Pebley was involved in a serious vehicle accident, sought medical care and filed suit. He had health coverage but decided not to submit his bills for payment. That is because, under California law, the jury would only hear about the amount paid by his health insurer as the measure of his medical expense while Pebley was billed at the top rate for medical services by refusing to use his health insurance.

The insurer cried foul, asserting that such actions mislead the jury, and are fraudulent because medical providers never expect to receive such high payments. They argued the plaintiff may present the higher medical bills but must provide expert testimony to prove the charges are fair and reasonable. Similarly, the defendant or their insurer may present counter-evidence as to what the health providers normally accept for payment of those services.

The California Second District Court of Appeal reasoned that juries should be allowed to ultimately decide the appropriate charge for the medical services. Parties are lining up to support an appeal of the case to the state Supreme Court. If Pebley succeeds in California, potentially winning the $3.6 million he seeks, the strategy of refusing to use health insurance can be expected to spread rapidly to other states.

Click here for full article.

Filed under Fraud, Personal Injury Protection (PIP)

Attorney Fee Multipliers in PIP and the Search for a Guiding Lodestar

In October 2017, the Supreme Court again addressed the issue of contingency fee multipliers to awards of attorneys’ fees. Personal Injury Protection (PIP) Plaintiff attorneys felt a tinge of delight and perhaps delayed buying their lottery tickets in hopes that this new decision will help them win an attorney fee multiplier if they prevail in a PIP suit. While HB 119 in 2012 eliminated multipliers from newer PIP lawsuits, there are still many older cases that are now being resolved which face the possibility of large awards of attorney fees going to Plaintiff attorneys. Additionally, there is no penalty for a Plaintiff attorney to attempt to pursue a multiplier, thus the key question is how to best defend against this potential windfall.

To understand the new decision in Joyce v. Federated Nat’l Ins. Co., 2017 Fla. LEXIS 2070 (Fla. 2017), it is beneficial to look back at the Florida Supreme Court’s interpretation of how and when to award a multiplier. The seminal decision regarding the applicability of multipliers is still the Quanstrom decision from 1990. Specifically, the requirements under Quanstrom necessary to find a fee multiplier are:

  1. Whether the relevant market requires a contingency fee multiplier to obtain competent counsel.
  2. Whether the attorney was able to mitigate the risk of non-payment in any way.
  3. Whether any of the factors set forth in Rowe are applicable, especially, the amount involved, the results obtained, and the type of fee arrangement between the attorney and his client. Id. at 834.

Joyce re-iterates that a market inquiry as to whether a multiplier was necessary to obtain competent counsel is the primary factor under the Quanstrom[1] requirements. This is important to PIP litigation since there are few, if any, potential PIP lawsuits that cannot find a warm and welcoming PIP attorney eager and willing to take the case.

Interestingly, the Florida Supreme Court in Joyce noted that the United States Supreme Court in 1992 revisited the issue of contingency fee multipliers in Burlington v. Dague, 505 U.S. 557 (1992), concluding that “enhancements for contingency [was] not permitted under the fee-shifting statutes at issue…[and] Justice Scalia, writing for the majority, reasoned that enhancement for contingency would likely duplicate in substantial part factors already subsumed in the lodestar.” Joyce. at 17, citing Dague at 567.

Under Joyce, the Florida Supreme Court separated itself from this federal precedent and continued to allow the use of multipliers under Florida law. The fear was that without the possibility of contingency multipliers some individuals with meritorious claims would fail to obtain competent counsel and the Florida Supreme Court noted “their usefulness in helping parties secure legal representation and their importance in ensuring access to Courts.” Id. at 17-18 citing Bell v. U.S.B. Acquisition Co., Inc., 734 So.2d 403, 411 (Fla. 1999). In other words, the Florida Supreme Court was concerned that Justice Scalia failed to consider that without a potential multiplier there is a danger of never obtaining competent counsel. Id. at 25. But with the thousands of PIP lawsuits being filed every year, can a Plaintiff truly make an argument that finding a PIP attorney is difficult?

Under Joyce, it appears that contingency fee multipliers are alive and well under Florida Law, and there are some circumstances where they are certainly warranted. Paradoxically, the best argument against the applicability of multipliers to the majority of PIP lawsuits comes from the Joyce opinion itself. The majority opinion which intentionally diverged from federal precedent on multipliers in order to preserve access to courts appears to have absolutely no concern about whether prohibiting multipliers in PIP lawsuits somehow prevents individuals from obtaining fair access to courts or diminishes one’s ability to obtain competent counsel. The dissent also argues that PIP litigation suffered no decrease in volume after HB 119 and that there was no negative impact on an insured’s ability to obtain counsel in PIP cases. Id. at 40-41. The dissent even cites the Plaintiff’s own expert testimony that there is no lack of attorneys willing and able to take PIP cases and “that same fee expert begrudgingly ‘hate[d]’ to admit that plaintiffs’ attorneys throughout the entire State of Florida are abundantly motivated to take PIP cases (even though PIP cases contain no possibility of a multiplier).” Id. at 42.

The majority opinion in Joyce actually agreed with the dissent that PIP litigation is different because of the number of attorneys willing to take PIP lawsuits. The majority opinion notes that PIP should not be compared to other types of first-party litigation since, “the fact that there are attorneys who specialize in PIP claims, which can be handled with relative ease in a volume practice, does not correlate with the availability of competent attorneys who are willing to litigate other types of insurance coverage cases, where generally more complex issues are raised.” Id. at 25. Clearly, the majority opinion is willing to differentiate PIP lawsuits from other types of first-party litigation due to the ease of obtaining a competent attorney.

Ultimately, none of the Quanstrom factors changed with the recent Joyce decision. However, the new opinion does provide an excellent analysis and justification as to how multipliers developed under Florida law and why the Supreme Court continues to think multipliers are necessary to ensure fair and equal access to the courts. It is important to keep in mind that Joyce does not mean a PIP lawsuit can never justify a multiplier. In fact, the Quanstrom decision is a PIP lawsuit[2]. Understanding the best way to contest aggressive attempts to collect fee multipliers and create an appropriate record at the trial court level remains important in PIP litigation.

[1] Standard Guaranty Insurance Co. v. Quanstrom,555 So.2d 828 (Fla. 1990)
[2] Other notable PIP lawsuits have been awarded multipliers after there was substantial and competent evidence to justify that a multiplier was necessary.  See  State Farm Fire & Casualty Co. v. Palma, 555 So.2d 836 (Fla. 1990)

If you have any questions on this issue, please feel free to contact our Insurance Services Team at info@roiglawyers.com.

ROIG Lawyers is a minority-owned litigation firm with a primary focus on Insurance Defense Litigation. We serve as primary counsel for numerous national and regional carriers and corporations related to all aspects of insurance litigation from seven offices throughout the state of Florida. ROIG Lawyers does not intend 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. E-mail list/s from ROIG Lawyers are intended to provide information of general interest to the public and are not intended to offer legal advice about specific situations or problems.  You should consult a lawyer with regard to specific legal issues that require attention.

Filed under Personal Injury Protection (PIP), Uncategorized

Florida Man Caught Staging Crash on Dashcam

According to the Sun Sentinel, a Florida man was arrested on Friday, October 6th in connection with an alleged staged crash that occurred in December of 2016. 65-year-old Mauril Aldophe of Delray Beach plotted to force a tow truck to rear-end him. Unfortunately for Mr. Aldophe, the tow truck was equipped with a dashcam capturing footage of him abruptly stopping for no apparent reason and then driving forward for several feet, throwing his car into reverse, and then slamming back into the tow truck.

According to investigators, Mr. Aldophe went to a medical clinic three days after the incident and filed a personal injury claim stating a truck had rear-ended him while he was stopped at a red light.

Mr. Aldophe now faces charges for insurance fraud and participation in an intentional crash.

Click here for full article.

Filed under Personal Injury Protection (PIP)

New Opinion Released Regarding Examinations Under Oath (EUOs)

A new opinion was recently released by the Florida 9th Circuit Court in its appellate capacity interpreting Fla. Stat. § 627.736(6)(g) and the timely scheduling of Examinations Under Oath (EUOs). This case reaffirms that as a general rule, an insurer ought to schedule the initial EUO in any claim under investigation to occur within 30 days of receipt of the first bill to ensure that the investigation is being conducted well within the time limits set forth in the PIP statute without obliging the insurer to issue a payment of the subject bill prior to investigation.

In Geico Indemnity Co. v. Central Florida Chiropractic Care a/a/o David Cherry (2016-CV-000038-A-O), Central Florida Chiropractic sued Geico for breach of contract for failure to pay overdue PIP benefits. Geico asserted as an affirmative defense that coverage was appropriately denied because the assignor failed to appear for two EUOs.

Central Florida Chiropractic contested Geico’s above-described defense because the EUOs were scheduled to occur more than 30 days after the date on which Central Florida Chiropractic had submitted the bills for the alleged charges at issue and, thus, the EUOs were unreasonably set to occur beyond the 30-day statutory period for payment of said bills. In fact, the Court noted, the first EUO request was not even sent until after 30 days had lapsed. Further, Geico had not informed the claimant pursuant to Fla. Stat. § 627.736(4)(i) that his claim was pending investigation.

The 9th Circuit ruled that even though attendance at an EUO is a condition precedent to receiving PIP benefits under Fla. Stat. § 627.736(6)(g), this provision “cannot be read in a vacuum.” The Court specifically looked to section (4)(b), which requires provider bills to be processed within 30 days of receipt, and to section (4)(i), which states that the claimant should be notified in writing within 30 days of filing the claim that an investigation is under way. Geico argued that section (4)(i) permits a 60-day extension of time for investigation beyond 30 days, but the Court pointed out that Geico failed to send any letter notifying the claimant of the investigation in this case, so the 30-day window was not extended.

The Court also explained that timely payment of the provider bills does not foreclose the insurer from investigating the claim. Nonetheless, “nothing in the statute additionally excuses the insurer’s potential breach for failure to pay a PIP claim within 30 days as contemplated by section 627.736(4)(b).”

Therefore, Geico could not enforce the EUO as condition precedent to receiving PIP benefits because by the time it had scheduled the EUOs, it was already in breach of the policy as the provider’s bills were not timely paid within 30 days. “[B]ecause Geico was already in breach of the insurance contract before the EUOs were scheduled to take place, [the assignor] was not obliged to submit to them.”

The Geico case is the latest in a long line of opinions and trial court orders, starting with Amador v. United Auto. Ins. Co., 748 So. 2d 307 (Fla. 3d DCA 1999), which holds that an EUO does not toll or extend the 30-day period within which an insurer must pay otherwise timely, compensable charges pursuant to Fla. Stat. § 627.736(4)(b). Courts have also ruled that the insurer does not comply with the 30-day requirement if it coordinates the EUO within 30 days, but the EUO is nonetheless scheduled to occur beyond the 30-day window. (See Micro-Diagnostics & South Florida Inst. of Medicina a/a/o Luz Solarte v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 248a (Fla. 11th Cir. Ct. App. 2004). In general, an insurer cannot defend claims on the basis of a claimant’s failure to attend an EUO if said EUO is scheduled to occur outside the 30-day period after submission of the medical bills. (See Humanitary Health Care, Inc. a/a/o Juan Esquivel v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 531b (Fla. 11th Cir. Ct. 2005).

However, a Miami-Dade appellate court did find that an insurer may still benefit from the claimant’s failure to appear for an EUO if said EUO is initially scheduled to occur within 30 days, but then rescheduled for a later date at the claimant’s request. (See West Dixie Rehab. & Medical Ctr. v. State Farm Fire & Casualty Co., 10 Fla. L. Weekly Supp. 16a (Fla. 11th Cir. Ct. App. 2002)).

The above cases make clear that any communications regarding the re-scheduling of an EUO ought to be done in writing, with language that clearly communicates that the change in date was done to accommodate the request of the insured or insured’s attorney. When appropriate, the insurer may send a letter to the claimant or claimant’s attorney pursuant to section (4)(i) advising that a claim is under investigation within 30 days of the claim filing. This will extend the time period within which an investigation may be conducted up to 90days after the submission of the claim, and thus allows additional time before any provider bills must be processed.

If you have any questions or would like to discuss this issue in greater detail, please feel free to contact us.

ROIG Lawyers is a minority-owned litigation firm with a primary focus on Insurance Defense Litigation. We serve as primary counsel for numerous national and regional carriers and corporations related to all aspects of insurance litigation from 7 offices throughout the state of Florida. ROIG Lawyers does not intend 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. E-mail list/s from ROIG Lawyers are intended to provide information of general interest to the public and are not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific legal issues that require attention.

Filed under Legislation, Personal Injury Protection (PIP)

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).

Filed under Personal Injury Protection (PIP)