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Nationwide Mutual Fire Insurance Co. v. Central Florida Physiatrists6/27/2003
Nationwide Mutual Fire Insurance Company (Nationwide) appeals the summary judgment entered by the county court in favor of Central Florida Physiatrists (CFP). The judgment required that Nationwide pay CFP the reasonable and necessary medical expenses incurred by Nationwide's PIP insured, not the reduced PPO amount for such services, because Nationwide had failed to comply with the provisions of section 627.736(10) of the Florida Statutes (1999) which authorized the payments of PPO amounts. The court also certified the following question to this court as being of great public importance:
IS AN INSURER REQUIRED TO COMPLY WITH THE PROVISIONS OF SECTION 627.736(10), FLA. STAT. (1999) IN ORDER TO TAKE PREFERRED PROVIDER REDUCTIONS IN THE PAYMENT OF PIP BENEFITS FOR MEDICAL SERVICES RENDERED TO ITS INSUREDS?
Finding no error, we affirm the county court's summary judgment order and answer the certified question in the affirmative.
CFP filed suit against Nationwide in county court seeking payment for medical services provided to Nationwide's PIP insured, Therese Jivoin. The pleadings explained that Jivoin had received medical treatment from CFP for injuries she sustained in an automobile accident. The payment for such treatment was covered by Jivoin's PIP policy. When Nationwide refused to pay the full amount charged by CFP for Jivoin's medical care, Jivoin assigned her rights to receive such payment to CFP. CFP, as assignee, thereafter sought recovery of the amount still owing on Jivoin's bill, as well as attorney's fees and costs. Nationwide defended, alleging that since CFP was a participating medical provider in the Beech Street PPO (a health care management provider), CFP was only entitled to be reimbursed at agreed PPO rates (not the PIP statutory rate of 80% of the usual, customary and related charges as set forth in section 627.736(1) of the Florida Statutes) because Nationwide was also a member of the Beech Street PPO.
CFP moved for summary judgment, alleging that since Nationwide had not directly contracted with CFP to be a part of a PPO, had not complied with the requirements of section 627.736(10)of the Florida Statute (1999), and had not sold Jivoin a PPO policy, Nationwide was not entitled to pay at the reduced PPO rate.
In entering summary judgment in favor of CFP, the trial court concluded that section 627.736(10) of the Florida Statutes (1999) provides the exclusive means by which an insurance company can pay PPO rates for PIP benefits, and that since Nationwide had failed to comply with the terms of the statute, it was not entitled to pay CFP at the reduced PPO rate. We agree.
Section 627.736 of the Florida Statutes (1999) provides, in pertinent part, as follows:
627.736. Required personal injury protection benefits; exclusions; priority; claims
(1) Required benefits.--Every insurance policy complying with the security requirements of s. 627.733 shall provide personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle, passengers in such motor vehicle, and other persons struck by such motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle, subject to the provisions of subsection (2) and paragraph (4)(d), to a limit of $10,000 for loss sustained by any such person as a result of bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as follows:
(a) Medical benefits.--Eighty percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devi
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