19 Fla. L. Weekly Supp. 948a
Online Reference: FLWSUPP 1911SAINInsurance — Personal injury protection — Coverage — Emergency services — Deductible — Because insurer is mandated by statute to reserve $5,000 for emergency medical service providers, insurer should not have applied claim filed by medical provider within that classification to deductible
EMERGENCY PHYSICIANS OF CENTRAL FLORIDA, LLP, as assignee of Oriol Saintilma, Plaintiff, v. DIRECT GENERAL INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 2011-SC-002170. July 16, 2012. Donald L. Marblestone, Judge. Counsel: Robert D. Bartles, Bradford Cederberg, P.A., Orlando, for Plaintiff. Neil Andrews, Adams & Diaco, P.A., Orlando, for Defendant.
AFFIRMED. 22 Fla. L. Weekly Supp. 209b
ORDER GRANTING PLAINTIFF’S MOTION FORFINAL SUMMARY JUDGMENT ANDDENYING DEFENDANT’S MOTION FORFINAL SUMMARY JUDGMENT
THIS MATTER having come before this Honorable Court on Plaintiff’s and Defendant’s Competing Motions for Partial Summary Judgment and this Honorable Court having heard arguments of counsel on the issue of whether providers of emergency services and care who submit their bill(s) in accordance with Florida Statute § 627.736(4)(c) are entitled to have their bill(s) paid regardless of the existence of a deductible, and the Court being otherwise fully advised in the premises, finds as follows:
1. The issue before the Court is a matter of first impression.
2. The parties stipulated to the facts and the Court hereby adopts the facts.FINDINGS OF FACT
3. On May 24, 2011, Oriol Saintilma (Saintilma) was involved in a motor vehicle accident.
4. On May 24, 2011, Saintilma was insured by Defendant under an automobile insurance policy.
5. The insurance policy provided Personal Injury Protection (PIP) coverage in the amount of $10,000 and the policy had a $1,000 deductible. The policy did not include medical payments coverage.
6. As a result of the May 24, 2011 motor vehicle accident, Saintilma sustained injuries and received medical treatment.
7. On May 25, 2011, Saintilma presented to Orlando Health wherein he received emergency services and care as defined by Florida Statute § 395.002(9) from Plaintiff, Emergency Physicians of Central Florida, LLP, the Emergency Department Physicians who serve the Orlando Health System.
8. Plaintiff charged $287 for the emergency services and care provided to Saintilma on May 25, 2011.
9. Defendant was notified of the motor vehicle accident on May 25, 2011.
10. On June 13, 2011, Defendant received Plaintiff’s bill for date of service May 25, 2011, which was within thirty (30) days of the date Defendant received notice of the motor vehicle accident.
11. Defendant allowed the Plaintiff’s charge of $287 in full. However, Defendant applied the Plaintiff’s charge to the $1,000 deductible.
12. Plaintiff moved for summary judgment alleging that, amongst other things, Florida Statute § 627.736(4)(c) mandated that PIP insurers reserve $5,000 in benefits for payment to physicians, such as Plaintiff who provide emergency services and care, thereby precluding Defendant from applying the bill to the deductible when the bill was received within thirty (30) days from the notice of accident.
CONCLUSIONS OF LAW AND RULING
13. It is well settled that in attempting to discern legislative intent, courts first look to the actual language used in the statute. Saleeby v. Rocky Elson Construction, Inc., 3 So. 3d 1078 (Fla. 2009) [34 Fla. L. Weekly S106a]; Vreuls v. Progressive Employer Services, 881 So. 2d 688 (Fla. 1st DCA 2004) [29 Fla. L. Weekly D1990b]. Additionally, when a statute is clear and unambiguous, the plain and ordinary meaning must control, unless this leads to an unreasonable result or a result clearly contrary to legislative intent. Id.
14. On January 1, 2008, the Legislature revived the PIP statute which created for the first time a mandatory set aside of $5,000 for payment of bills submitted by a special class of providers. Florida Statute § 627.736(4)(c) states in relevant part:
Upon receiving notice of an accident that is potentially covered by personal injury protection benefits, the insurer must reserve $5,000 of personal injury protection benefits for payment to physicians licensed under chapter 458 or chapter 459 or dentists licensed under chapter 466 who provide emergency services and care, as defined in s. 395.002(9), or who provide hospital inpatient care. The amount required to be held in reserve may be used only to pay claims from such physicians or dentists until 30 days after the date the insurer receives notice of the accident. After the 30-day period, any amount of the reserve for which the insurer has not received notice_of a claim from a physician or dentist who provided emergency services and care or who provided hospital inpatient care may then be used_by the insurer to pay other claims. The time periods specified in paragraph (b) for required payment of personal injury protection benefits shall be tolled for the period of time that an insurer is required by this paragraph to hold payment of a claim that is not from a physician or dentist who provided emergency services and care or who provided hospital inpatient care to the extent that the personal injury protection benefits not held in reserve are insufficient to pay the claim. This paragraph does not require an insurer to establish a claim reserve for insurance accounting purposes.
15. The Court agrees with Plaintiff and finds that the language of Florida Statute § 627.736(4)(c) is clear and unambiguous. PIP insurers must reserve $5,000 of PIP benefits for payment to physicians licensed under the stated chapters of Florida Statute § 627.736 (4)(c) and the $5,000 may only be used to pay claims for such physicians until 30 days after the date the insurer receives notice of an accident.
16. The Legislature did not address the deductible and/or the application of a deductible to the selected group of emergency medical providers in Florida Statute § 627.736(4)(c).
17. Based on the plain language of the statute, Plaintiff satisfied all of the requirements set forth in Florida Statute § 627.736(4)(c) and therefore Defendant was obligated to reserve benefits for payment to Plaintiff and should not have applied the bill to the deductible.
18. Therefore the Plaintiff’s bill should have been paid from the mandated $5,000 reserve.
19. Accordingly, the Court grants Plaintiff’s Motion for Partial Summary Judgment and Denies Defendant’s Motion for Partial Summary Judgment.
20. Following the summary judgment hearing, the parties stipulated that in this case the Plaintiff’s services were reasonable, related and medically necessary and that the Plaintiff’s charge was reasonable.
21. Based on the parties stipulation, there are no remaining issues of fact in dispute and Plaintiff is entitled to Final Summary Judgment as a matter of law.
22. Final Judgment is hereby granted in favor of Plaintiff, Emergency Physicians of Central Florida, LLP a/a/o Oriol Saintilma, wherein Plaintiff shall recover from Defendant, Direct General Insurance Company, the sum of $229.60 plus 6% interest in the amount of $15.13 for a total sum of $244.73 for which sum let execution. Post judgment interest of 4.75% per annum shall be due on this judgment pursuant to Fla. Stat. § 55.03.
23. The Court finds that Plaintiff is entitled to reasonable attorney’s fees and costs. The Court reserves jurisdiction to determine the amount of Plaintiff’s attorney’s fees and costs pursuant to Fla. Stat. §§ 627.736, 627.428 and 57.041.
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