Allstate Insurance Company v. Revival Chiropractic, LLC

CourtSupreme Court of Florida
DecidedApril 25, 2024
DocketSC2022-0735
StatusPublished

This text of Allstate Insurance Company v. Revival Chiropractic, LLC (Allstate Insurance Company v. Revival Chiropractic, LLC) is published on Counsel Stack Legal Research, covering Supreme Court of Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Allstate Insurance Company v. Revival Chiropractic, LLC, (Fla. 2024).

Opinion

Supreme Court of Florida ____________

No. SC2022-0735 ____________

ALLSTATE INSURANCE COMPANY, et al., Appellants,

vs.

REVIVAL CHIROPRACTIC, LLC, Appellee.

April 25, 2024

PER CURIAM.

Once again, we address a dispute over the amount of

reimbursements for medical expenses that an insurer was required

to pay under a personal injury protection (PIP) policy. This dispute

comes to us by way of a certified question posed by the United

States Court of Appeals for the Eleventh Circuit in Revival

Chiropractic LLC ex rel. Padin v. Allstate Insurance Co., No. 21-

10559, 2022 WL 1799759, at *1 (11th Cir. June 2, 2022), which we

consider under the jurisdiction granted by article V, section 3(b)(6)

of the Florida Constitution to review questions of Florida law certified by federal appellate courts that are “determinative of the

cause and for which there is no controlling precedent” of our Court.

Like our recent decision in MRI Associates of Tampa, Inc. v.

State Farm Mutual Automobile Insurance Co., 334 So. 3d 577 (Fla.

2021), this case involves the interaction of the PIP statute’s

foundational requirement that insurers pay 80% of “all reasonable

expenses” for medically necessary services with the statutory

authorization for an insurer to pay 80% of expenses based on the

statutory schedule of maximum charges if the insurer gives notice

that it may limit reimbursement pursuant to that schedule.

Reduced to its bare bones, the question for decision is whether the

insurer here may pay 80% of a charge submitted by a provider even

when that reimbursement amount is less than the amount that

would be reimbursable under the limitations of the statutory

schedule of maximum charges. We conclude that the terms of the

PIP policy in this case expressly authorize such a payment and that

nothing in the statutory scheme stands in the way of that policy

provision.

In analyzing the case, we first briefly review the relevant

statutory provisions before setting forth the pertinent policy

-2- provisions. With that groundwork laid, we discuss the opinion of

the Eleventh Circuit, which describes the controversy and the

arguments of the parties, and we examine the decision of the United

States District Court for the Middle District of Florida that is on

review in the Eleventh Circuit. We then discuss Florida case law,

focusing on our decision in MRI Associates. Finally, we rephrase

the certified question to more carefully track the facts of the case

after we have analyzed the relevant statutory and policy provisions

and explained our conclusion that Allstate was entitled to pay 80%

of the billed charges at issue here.

I.

The statutory requirements governing PIP benefits are set forth

in section 627.736, Florida Statutes (2017). Section 627.736(1)(a)

provides generally that PIP medical benefits must cover “[e]ighty

percent of all reasonable expenses for medically necessary medical,

surgical, X-ray, dental, and rehabilitative services.” Comprehensive

provisions regarding “charges for treatment of injured persons” are

laid out in section 627.736(5). Subsection (5)(a) requires that

medical providers “rendering treatment to an injured person for a

bodily injury covered by personal injury protection insurance may

-3- charge the insurer and injured party only a reasonable amount

pursuant to this section for the services and supplies rendered” and

then enumerates various factors relevant to ascertaining the

reasonableness of charges. Subsection (5)(a) moves on to set forth

provisions creating and governing the schedule of maximum

charges that may be used to limit reimbursement.

Subsection (5)(a) states that reasonable charges “may not

exceed the amount the [provider] customarily charges for like

services or supplies.” Subsection (5)(a) then sets forth various

factors that may be used in determining the reasonableness of

charges, including “evidence of usual and customary charges and

payments accepted by the provider involved in the dispute.”

Provisions related to the schedule of maximum charges are

contained in section 627.736(5)(a)1. Under this provision, “[t]he

insurer may limit reimbursement to 80 percent of the [listed] schedule

of maximum charges” set forth in subsection (5)(a)1.a.-f. (Emphasis

added.)

Various requirements concerning the application of the

schedule of maximum charges are detailed in subsection (5)(a)2.-5.

Of particular relevance to the issue in this case, subsection (5)(a)5.

-4- requires that an insurer provide notice of its election to use the

schedule of maximum charges:

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. . . . 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.

(Emphasis added.)

II.

Under the PIP policy provisions at issue in this case, Allstate

agreed—subject to various conditions—to pay “eighty percent of

reasonable expenses” for “medically necessary” services. Allstate’s

policy further states that “[t]he methodology for determining the

amount” to be paid “shall, pursuant to the fee schedule limitations

under Section 627.736(5)(a)1. . . . or any other limitations

established by Section 627.736 . . . or any other provisions of the

Florida Motor Vehicle No-Fault Law, as enacted, amended or

otherwise continued in the law, be limited to eighty percent of [a

listed] schedule of maximum charges” that parallels the statutory

schedule “(or any other fee schedule limitation which may be

-5- enacted, amended or otherwise continued in the law).” (Emphasis

The policy goes on to provide: “If a provider submits a charge

for an amount less than the amount determined by the fee schedule

or other limitations established by Section 627.736 . . . or any other

provisions of the Florida Motor Vehicle No-Fault Law . . . [Allstate]

will pay eighty percent of the charge that was submitted.”

III.

As the Eleventh Circuit explained, Allstate issued separate

auto insurance policies—both containing the PIP provisions set

forth above—to Natalie Rivera and Jazmine Padin. Revival

Chiropractic ex rel. Padin, 2022 WL 1799759, at *1. The circuit

court detailed the genesis of this litigation:

Padin and Rivera were both involved in car accidents, and they sought treatment from Revival. They also assigned to Revival any rights and benefits that they had under their respective policies. After rendering services to these insureds, Revival submitted a charge of $100. The services corresponded to a maximum charge of $149.92 under the statutory schedule. So 80% of the maximum charge under the schedule was $119.94, which was higher than the submitted charge. See Fla. Stat. § 627.736(5)(a)1. Because the charge of $100 was less than $119.94, the

-6- statute expressly allowed Allstate to pay the amount billed. Id. § 627.736(5)(a)5. Instead of paying the scheduled amount or amount billed, Allstate chose to pay 80% of the amount billed—$80.

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Allstate Insurance Company v. Revival Chiropractic, LLC, Counsel Stack Legal Research, https://law.counselstack.com/opinion/allstate-insurance-company-v-revival-chiropractic-llc-fla-2024.