A & M Gerber Chiropractic LLC v. GEICO Gen. Ins. Co.

291 F. Supp. 3d 1318
CourtDistrict Court, S.D. Florida
DecidedNovember 17, 2017
DocketCase No. 16–cv–62610–BLOOM/Valle
StatusPublished
Cited by4 cases

This text of 291 F. Supp. 3d 1318 (A & M Gerber Chiropractic LLC v. GEICO Gen. Ins. Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
A & M Gerber Chiropractic LLC v. GEICO Gen. Ins. Co., 291 F. Supp. 3d 1318 (S.D. Fla. 2017).

Opinion

BETH BLOOM, UNITED STATES DISTRICT JUDGE

THIS CAUSE is before the Court upon Plaintiff A & M Gerber Chiropractic LLC's ("Plaintiff") Motion for Partial Summary Judgment, ECF No. [59] ("Plaintiff's Motion for Summary Judgment"), Defendant GEICO General Insurance Company's ("GEICO") Motion for Summary Judgment, ECF No. [80] ("GEICO's Motion for Summary Judgment"), and GEICO's Motion to Disqualify Class Representative, ECF No. [161] ("Motion to Disqualify"), (collectively the "Motions"). The Court has carefully considered the Motions, all supporting and opposing filings, the relevant authorities, has heard oral argument by the parties, and is otherwise duly advised. For the reasons that follow, the Motion to Disqualify is denied, Plaintiff's Motion for Summary Judgment is granted, and GEICO's Motion for Summary Judgment is denied.

I. BACKGROUND1

A. The Policy

This class action lawsuit seeks a declaration as to the meaning of a single sentence contained within a GEICO insurance policy as explained below. Plaintiff is a health care provider that rendered health care services to Conor Carruthers ("Carruthers") for injuries he sustained in an automobile accident in March of 2015. See ECF No. [59] at ¶ 11. Carruthers was insured under a policy with GEICO that provided personal injury protection ("PIP") motor vehicle insurance benefits (the "Policy"). See ECF No. [81] at ¶ 1. The Policy provides coverage for PIP claims pursuant to Florida Statute § 626.736. See ECF No. [59] at ¶ 5. The Policy also contains an endorsement to the PIP coverage identified as FLPIP (01-13) (the "FLPIP (01-13) Endorsement"), which became effective January 1, 2013. See ECF No. [67-1]. The FLPIP (01-13) Endorsement states, in pertinent part, as follows:

PAYMENTS WE WILL MAKE
The Company will pay in accordance with the Florida Motor Vehicle No Fault *1323Law (as enacted, amended, or newly enacted), and where applicable in accordance with all fee schedules contained in the Florida Motor Vehicle No Fault Law, to or for the benefit of the injured person:
(A) Eighty percent (80%) of medical benefits which are medically necessary , pursuant to the following schedule of maximum charges contained in the Florida Statutes § 627.736(5)(a) 1., (a)2., and (a)3.:
...
6. For all other medical services, supplies, and care, 200 percent of the allowable amount under:
(I.) The participating physicians fee schedule of Medicare Part B...
However, if such services, supplies, or care is not reimbursable under Medicare Part B (as provided in section (A)6. above), we will limit reimbursement to eighty percent (80%) of the maximum reimbursable allowance under workers' compensation, as determined under Florida Statutes, § 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided.
...
A charge submitted by a provider, for an amount less than the amount allowed above, shall be paid in the amount of the charge submitted.
...

ECF No. [67-1] at 31 (emphasis in original). The terms of the FLPIP (01-13) Endorsement quoted above have not changed since they went into effect on January 1, 2013. See ECF No. [59] at ¶ 8. The dispute in this case centers on the meaning of one sentence: "A charge submitted by a provider, for an amount less than the amount allowed above, shall be paid in the amount of the charge submitted." ECF No. [67-1] at 31.

In addition to the FLPIP (01-13) Endorsement, the Policy contains a document identified as M608 (01-13). See ECF No. [94] at ¶ 23. Although the parties dispute whether this document is a notice or an endorsement and whether its language has any effect on FLPIP (01-13), neither party disputes the content or authenticity of the document. In addition, the parties are in agreement that this document was mailed to policyholders for all new policies effective on or after January 1, 2013 and all renewal policies effective on or after January 1, 2013. Moreover, the parties agree that and that it was mailed in an effort to comply with § 627.736(5)(a) 5. and House Bill 119, which are further discussed below. See ECF No. [81] at ¶ 4; ECF No. [89] at ¶ 4. The M608 (01-13) document states as follows:

IMPORTANT NOTICE
FEE SCHEDULE ENDORSEMENT
USE OF MEDICAL FEE SCHEDULE FOR PERSONAL INJURY PROTECTION CLAIMS THIS NOTICE IS ENCLOSED IN COMPLIANCE WITH FLORIDA STATUTE 627.736
Effective January 1, 2013
The Company will limit reimbursement of medical expenses to 80 percent of a properly billed reasonable charge, but in no event will the Company pay more than 80 percent of the following schedule of maximum charges:
...
6. For all other medical services, supplies, and care, 200 percent of the allowable amount under:
(I.) The participating physicians fee schedule of Medicare Part B...
However, if such services, supplies, or care is not reimbursable under Medicare Part B (as provided in section 6. above), we will limit reimbursement to eighty percent (80%) of the maximum reimbursable *1324allowance under workers' compensation, as determined under Florida Statutes, § 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided ...

ECF No. [67-1] at 51.

Within the Policy, GEICO also elected the fee schedules referred to in Florida Statute § 627.736(5)(a) 1.a-f. See ECF No. [59] at ¶ 5. As it relates to the election of fee schedules, in 2012, the Florida Legislature amended § 617.736(5)(a)5. to state the following:

Effective July 1, 2012, an insurer may limit payment as authorized by this paragraph only if the insurance policy includes a notice at the time of issuance or renewal that the insurer may limit payment pursuant to the schedule of charges specified in this paragraph. A policy form approved by the office satisfies this requirement. If a provider submits a charge for an amount less than the amount allowed under subparagraph 1., the insurer may pay the amount of the charge submitted.

Fla. Stat. § 617.736(5)(a)5. Pursuant to this new statutory requirement, the Florida Office of Insurance Regulation issued Informational Memorandum OIR-12-02M (the "Informational Memorandum"). See ECF No. [67-4].

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
291 F. Supp. 3d 1318, Counsel Stack Legal Research, https://law.counselstack.com/opinion/a-m-gerber-chiropractic-llc-v-geico-gen-ins-co-flsd-2017.