Emergency Medical Condition Must Exist For No-Fault Benefits Over $2,500, Florida's Fourth District Court of Appeals Confirms
Date Published: 08-31-2016
Above: Colodny Fass Lawyers Maria Elena Abate and Raquel Moya Represent National, Florida Insurance Trade Associations With Successful Amicus Brief
Recent attempts by medical providers to work around Florida's $2,500 legislative cap on Personal Injury Protection ("PIP") insurance benefits in cases where there has been no determination whether the injuries for which treatment is sought constitute an "emergency condition" were shut down earlier today, August 31, 2016, by the Fourth District Court of Appeal's ("DCA's") answer to a certified question of great public importance:
"[B]enefits above $2,500 are available only where a medical provider determines an emergency medical condition exists. Where a medical provider does not make a determination that there is an emergency medical condition benefits above $2,500 are not available."
Colodny Fass lawyers Maria Elena Abate and Raquel Moya represented amici curiae, the Property Casualty Insurers of America and the Personal Insurance Federation of Florida in the case of Medical Center of the Palm Beaches d/b/a Central Palm Beach Physicians and Urgent Care Inc., a/a/o Carmen Santiago v. USAA Casualty Insurance Company, No. 4D14-3580.
A copy of the Amicus brief is attached for review.
Carmen Santiago was injured in a car accident and proceeded to an urgent care center with pain in her cervical region and shoulder. She was referred by a doctor to physical therapy. USAA requested a "determination of the patient's emergency medical condition by a provider authorized" but it was never obtained. USAA paid up to the $2500 cap. Litigation ensued and during litigation, USAA received the requested determination from Ms. Santiago's treating doctor. USAA then paid up to the ten thousand dollars in benefits. The providers then argued that there had been a confession of judgment and sought fees. The trial court disagreed and certified a question of great public importance.
The question as rephrased by the Fourth DCA is as follows:
IN AN ACTION BY AN ASSIGNEE FOR NO FAULT INSURANCE BENEFITS UNDER A POLICY OF MOTOR VEHICLE INSURANCE, ARE BENEFITS ABOVE $2500 ONLY AVAILABLE WHERE THERE HAS BEEN A DETERMINATION BY A MEDICAL PROVIDER AUTHORIZED BY STATUTE THAT AN EMERGENCY MEDICAL CONDITION EXISTS, AS DEFINED IN THE FLORIDA NO-FAULT LAW?
Finding the PIP Statute to be ambiguous, the Fourth DCA turned to legislative history and intent and relied heavily on the Eleventh Circuit Court of Appeal's analysis in the case of Robbins v. Garrison Property and Casualty Insurance Co., 809 F.3d 583 (11th Cir. 2015) which recognized that an affirmative determination had to be made in order for the cap to be lifted.
In their amici brief, the Property Casualty Insurers of America and the Personal Insurance Federation of Florida explained in detail that the Florida Legislature's intent was clear in that all concerned parties understood $2,500 to be the cap on PIP benefits absent a finding of an emergency medical condition.
More importantly, the brief also noted how those 2012 Reforms have positively impacted the PIP landscape.
A 2014 Report by the Florida Office of Insurance Regulation regarding the impact of the PIP Reforms ("Report on Review of the Data Call Pursuant to House Bill 119 - Motor Vehicle Personal Injury Protection (PIP) Insurance" (January 1, 2015)) only two years after the bill's passage, confirmed a 16 percent decrease in PIP fraud and a 13.6 percent decrease in premiums.
The Fourth District's opinion is not final until the time for rehearing has expired.
To access today's Fourth DCA opinion, click here.
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11424_Medical Center v USAA Amici Brief.PDF