Nationwide Mut. Ins. Co. v. Jewell

862 So. 2d 79, 2003 WL 22681113
CourtDistrict Court of Appeal of Florida
DecidedNovember 14, 2003
Docket2D01-5714, 2D02-871
StatusPublished
Cited by3 cases

This text of 862 So. 2d 79 (Nationwide Mut. Ins. Co. v. Jewell) is published on Counsel Stack Legal Research, covering District Court of Appeal of Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Nationwide Mut. Ins. Co. v. Jewell, 862 So. 2d 79, 2003 WL 22681113 (Fla. Ct. App. 2003).

Opinion

862 So.2d 79 (2003)

NATIONWIDE MUTUAL INSURANCE COMPANY, an Ohio corporation, Appellant,
v.
Dennis M. JEWELL, D.C., P.A. a/a/o Thomas Forberger, Linda Stone, and Ralph Stone, and George G. Hudson, D.C., P.A. d/b/a Hudson Chiropractic a/a/o Julie Odenweller and James Cafaro, Appellees.
Nationwide Mutual Fire Insurance Company, an Ohio corporation, Appellant,
v.
Jeff Davis, D.C., P.A. a/a/o Angela Richards, Appellee.

Nos. 2D01-5714, 2D02-871.

District Court of Appeal of Florida, Second District.

November 14, 2003.
Rehearing Denied December 19, 2003.

*80 W. Donald Cox, Charles Tyler Cone and Bruce Allen Aebel of Fowler White Boggs Banker P.A., Tampa, for Appellants.

George A. Vaka of Vaka, Larson & Johnson, P.L., Tampa, and Scott A. Schieb and Steven T. Wittmer, Sarasota, for Appellees Dennis M. Jewell, D.C., P.A. and George G. Hudson, D.C., P.A.

Eric Lee of Lee & Amtzis, P.L., Boca Raton, for Appellee Jeff Davis, D.C., P.A.

William F. Merlin, Jr., and Mary E. Kestenbaum of Gunn Merlin, P.A., Tampa, for Amicus Curiae Academy of Florida Trial Lawyers.

Gregory A. Victor of Adorno & Yoss, P.A., Miami, for Amicus Curiae ADP Integrated Medical Solutions, Inc.

Kathy J. Maus and Lola M. Swaby of Butler Burnette Pappas LLP, Tallassee, for Amicus Curiae The Alliance of American Insurers.

Jeffery M. Scott, Tallahassee, for Amicus Curiae Florida Medical Assoc.

Peter J. Valeta of Ross & Hardies, Chicago, and David B. Shelton of Rumberger, Kirk & Caldwell, Orlando, for Amicus Curiae Allstate Insurance Co. and Florida Defense Lawyers Association.

Laura M. Watson of Watson & Lentner, Ft. Lauderdale, for Amicus Curiae Florida *81 Hospital Assoc., and Florida Orthopaedic Society.

CANADY, Judge.

These consolidated cases, which are before this court pursuant to the certification of a question of great public importance under Florida Rule of Appellate Procedure 9.160, turn on the interpretation of provisions of the Florida Motor Vehicle No-Fault Law.[1] The appellants, insurers under the no-fault statute, seek review of trial court determinations that the statute prohibited them from making payment for health care services covered by personal injury protection (PIP) benefits at reduced preferred provider organization (PPO) rates to the appellee health care providers. Because we conclude that the no-fault law does not prohibit the payment of reduced PPO rates by the appellant insurers for PIP benefits, we reverse the judgments of the courts below.

I. BACKGROUND

Dennis M. Jewell, D.C., P.A., and George G. Hudson, D.C., P.A., brought separate actions against Nationwide Mutual Insurance Company in the Sarasota County Court. The Jewell and Hudson actions were consolidated for consideration by the Sarasota County Court. Jeff Davis, D.C., P.A., brought an action against Nationwide Mutual Fire Insurance Company in the Hillsborough County Court. Jewell, Hudson, and Davis, the appellee providers, each brought their actions as assignees of patients to whom they had provided treatment covered by the patients' PIP insurance. The appellee providers each claimed that the PIP insurer had failed to pay the full amounts due for covered medical services under the no-fault law. The insurers in each case had paid the appellee providers at a reduced PPO rate.

The insurers asserted a right to pay the providers at the reduced PPO rate because the appellee providers had entered "provider agreements" with at least one PPO network (namely, Beech Street Corporation or CNN), with which the insurers had entered a "payor contract." Under provider agreements, health care providers agree to provide medical services to certain patients and to accept payment for those services under a schedule of reduced PPO rates and thus, in effect, join the PPO network with which they have contracted. Insurers and employers, which are the payors for health care benefits, enter payor contracts with the PPO networks. Under those contracts, the insurers or employers make a pool of patients available to the PPO network providers and are entitled to the benefit of the reduced PPO rates which network providers have agreed to charge under the provider agreements they have entered.

In these consolidated cases there are unresolved issues concerning whether the services provided by the appellee providers were within the scope of a provider agreement that was in force at the time the services were rendered. Those issues were left unresolved because the two trial courts determined that, regardless of the contractual undertakings by the appellee providers, the appellant insurers, and the PPO networks, the insurers were statutorily barred from paying providers at PPO rates. We do not address those unresolved issues.

Both trial courts held that section 627.736(10), Florida Statutes (2000), sets forth the only circumstances under which a PIP insurer may pay medical benefits at a PPO rate. That subsection authorizes PIP insurers to enter preferred provider *82 contracts with health care providers. The subsection also authorizes the issuance of preferred provider PIP policies if the specified requirements of the subsection are met. The trial courts both concluded that the legislative authorization of contracts between PIP insurers and preferred providers and the authorization of preferred provider PIP policies by implication prohibited the utilization by PIP insurers of a PPO network where the insurers had not entered direct contracts with the preferred providers and had not issued preferred provider policies. Since the appellant insurers admittedly did not have direct contracts with the appellees and had not issued preferred provider policies as authorized by section 627.736(10), the trial courts ruled that the appellant insurers were not entitled to pay the appellee providers PPO rates.

II. CERTIFIED QUESTION

Each trial court, pursuant to the agreement of the parties, certified the following question to this court:

WHETHER [A PIP INSURER] COULD PAY [PIP] BENEFITS AT REDUCED [PPO] RATES WITHOUT OFFERING A PREFERRED PROVIDER PIP POLICY OF INSURANCE AND/OR WITHOUT COMPLYING WITH [SECTION 627.736(10), FLORIDA STATUTES].

For the reasons set forth below, we conclude that the insurers' asserted contractual basis for paying PPO rates to the appellee providers is not affected by the provisions of section 627.736(10). We therefore answer the certified question in the affirmative.

III. ANALYSIS

Section 627.736 sets forth the medical, disability, and death benefits that are required to be included in all PIP insurance policies. Under section 627.736(1)(a), benefits are required for "[e]ighty percent of all reasonable expenses for medically necessary medical ... services." Section 627.736(5)(a) provides further that

[a]ny physician ... lawfully rendering treatment to an injured person for a bodily injury covered by personal injury protection insurance may charge only a reasonable amount for the services and supplies rendered.... In no event, however, may such a charge be in excess of the amount the person ... customarily charges for like services ... in cases involving no insurance.

Section 627.736(10)—which is the subject of the certified question—provides:

An insurer may negotiate and enter into contracts with licensed health care providers for the benefits described in this section, referred to in this section as "preferred providers," which shall include health care providers licensed under chapters 458, 459, 460, 461, and 463.

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Related

Allstate Ins. Co. v. Holy Cross Hosp., Inc.
961 So. 2d 328 (Supreme Court of Florida, 2007)
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Cite This Page — Counsel Stack

Bluebook (online)
862 So. 2d 79, 2003 WL 22681113, Counsel Stack Legal Research, https://law.counselstack.com/opinion/nationwide-mut-ins-co-v-jewell-fladistctapp-2003.