Court Opinion

ID: 6323808
Source: CourtListenerOpinion
Date Created: 2022-03-16 15:03:38.620877+00
Date Added: 2024-06-11T09:21:43.880977
License: Public Domain

DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA
                              FOURTH DISTRICT

       ALLSTATE FIRE AND CASUALTY INSURANCE COMPANY,
                          Appellant,

                                      v.

      SPORTS, SPINE, OCCUPATIONAL, REHABILITATION, INC.,
                     a/a/o JUNE RICHARDS,
                            Appellee.

                               No. 4D21-817

                              [March 16, 2022]

   Appeal from the County Court for the Seventeenth Judicial Circuit,
Broward County; Steven DeLuca, Judge; L.T. Case No. CONO 16-003651.

   Daniel E. Nordby and Jason Gonzalez of Shutts & Bowen LLP,
Tallahassee, and Garrett A. Tozier of Shutts & Bowen LLP, Tampa, for
appellant.

   Douglas H. Stein of Douglas H. Stein, P.A., Coral Gables, for appellee.

CONNER, C.J.

   Allstate Fire and Casualty Insurance Company (“Allstate”) appeals the
final judgment awarding damages to Sports, Spine, Occupational,
Rehabilitation, Inc. (“the Provider”), as assignee of June Richards (“the
insured”), following cross motions for summary judgment. Allstate argues
the damages award was erroneous where the entire amount billed for the
Provider’s single claim was within the insured’s deductible. We agree and
reverse.

    Allstate issued an automobile insurance policy to the insured providing
personal injury protection (“PIP”) benefits. After the insured’s automobile
accident, the Provider rendered medical treatment to the insured, who
assigned payment of policy benefits to the Provider. The Provider was the
first claimant to submit a bill to Allstate for service rendered to the insured
after the accident. The claim was for $495. Allstate determined the
covered amount for the service was $352.28 after applying the fee schedule
provided for in the policy. Allstate’s “explanation of benefits” stated that
the reduced amount of $352.28 was then applied to the insured’s $1000
deductible under the policy, resulting in no payment to the Provider. The
Provider’s bill was also the first charge applied to the deductible.
Subsequently, the insured’s deductible was exhausted through charges of
another provider who is not a party to the suit.

   The Provider sued Allstate for PIP benefits. While the suit was pending,
our supreme court decided Progressive Select Insurance Co. v. Florida
Hospital Medical Center, 260 So. 3d 219 (Fla. 2018). In Progressive Select,
the supreme court held that “section 627.739(2)[, Florida Statutes,]
requires the deductible to be applied to the total medical charges prior to
reduction    under     the    reimbursement      limitation    in    section
627.736(5)(a)1.b.” Id. at 221. After Progressive Select issued, the Provider
moved for summary judgment, contending that Allstate did not apply the
deductible correctly to its claim, resulting in damage to the Provider
because section 627.736(5)(a)4., Florida Statutes (2016), prohibited the
Provider from seeking payment from the insured for an amount that
exceeded the reduced amount stated in the explanation of benefits issued
on the Provider’s claim. 1 The trial court agreed and granted summary
judgment in the Provider’s favor.

   On appeal, Allstate concedes, as it did below, that it improperly applied
the deductible to the Provider’s claim. However, Allstate argues that even
had it properly applied the entire $495 billed amount to the $1000
deductible, the deductible would not have been exhausted, such that it
had no obligation under the PIP policy to pay PIP benefits.

    Allstate correctly notes the distinction between an insured’s obligation
in relation to the deductible and an insurer’s obligation to pay PIP benefits:

         Before the deductible is satisfied, “the insurer is not
         reimbursing the medical provider”; rather, the
         policyholder is compensating the provider. USAA Gen.
         Indem. Co. v. Gogan, 238 So. 3d 937, 943 (Fla. 4th DCA 2018)

1   Section 627.736(5)(a)4. provides:

         If an insurer limits payment as authorized by subparagraph 1., the
         person providing such services, supplies, or care may not bill or
         attempt to collect from the insured any amount in excess of such
         limits, except for amounts that are not covered by the insured’s
         personal injury protection coverage due to the coinsurance amount
         or maximum policy limits.

§ 627.736(5)(a)4., Fla. Stat. (2016).

                                         2
      (Gross, J., dissenting); see Int’l Bankers Ins. Co. v. Arnone, 552
      So. 2d 908, 911 (Fla. 1989) (stating that “an insurance
      company’s obligation to pay” will not “ripen” until the
      deductible is met). There is no basis for concluding that the
      reimbursement limitation applies to charges included in the
      deductible, “which the insured alone is obligated to pay and
      which are not recoverable as benefits under the policy.”
      Progressive [Select Ins. Co. v. Fla. Hosp. Med. Ctr. a/a/o/
      Jonathan Parent], 236 So. 3d [1183, 1191, (Fla. 5th DCA
      2018)].

Progressive Select, 260 So. 3d at 224 (emphasis added).

    In the instant case, entitlement to PIP benefits “ripened” only after the
full amount of the $1000 deductible was met. Therefore, Allstate is correct
that even if it had properly applied the full amount of the Provider’s first-
submitted bill to the deductible, the deductible would not have been
exhausted and Allstate would not have been responsible for paying any
portion of the Provider’s bill. Because the Provider’s entire billed amount
was not enough to exhaust the deductible and “ripen” Allstate’s obligation
to pay PIP benefits, the Provider was not entitled to PIP benefits. 2

   Based on the foregoing, we reverse and remand for the trial court to
vacate the final judgment in the Provider’s favor and for further
proceedings.

    Reversed and remanded.

GROSS and MAY, JJ., concur.

                              *         *         *

    Not final until disposition of timely filed motion for rehearing.

2Because the entitlement to PIP benefits never “ripened,” we reject the Provider’s
arguments that it was entitled to consequential damages.

                                        3