Allstate Fire & Casualty Insurance v. Stand-Up MRI of Tallahassee, P.A.
188 So. 3d 1
Fla. Dist. Ct. App.2015Background
- Stand-Up MRI, as assignee of PIP benefits for 14 insureds, sued Allstate in county court claiming Allstate improperly limited PIP reimbursements by using Medicare fee schedules without adequate policy notice.
- The county court agreed with Stand-Up MRI and certified a question of great public importance to the First District Court of Appeal.
- The legal question centered on whether Allstate’s policy language gave the notice required by the Florida Supreme Court in Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc., 141 So.3d 147 (Fla. 2013), before an insurer may limit reimbursements using the § 627.736(5)(a)2 Medicare-based fee schedules.
- Allstate’s policy stated it would pay “eighty percent of reasonable expenses” for medically necessary services and that “Any amounts payable under this coverage shall be subject to any and all limitations authorized by section 627.736…, including, but not limited to, all fee schedules.”
- The district court reviewed the policy de novo and compared Allstate’s language to the policy language the Florida Supreme Court found sufficient (amended Geico language) and insufficient (Geico’s earlier language) in Virtual Imaging.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Allstate’s policy provided the notice required by Virtual Imaging to permit limiting PIP reimbursements by Medicare fee schedules | Stand-Up MRI: policy is ambiguous; “subject to” does not clearly elect fee-schedule limitations, so insurer cannot invoke them | Allstate: policy expressly subjects payments to § 627.736 limitations, “including…all fee schedules,” satisfying Virtual Imaging’s notice requirement | Court held Allstate’s language plainly and unambiguously provided the required notice and authorized use of Medicare fee schedules |
Key Cases Cited
- Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc., 141 So.3d 147 (Fla. 2013) (requires insurer policy notice electing Medicare fee schedules before limiting PIP reimbursements)
- State Farm Mut. Auto. Ins. Co. v. Menendez, 70 So.3d 566 (Fla. 2011) (interpret policy language according to plain meaning when unambiguous)
- Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So.3d 63 (Fla. 4th DCA 2011) (discusses insurer election of fee-schedule limitations as notice precedent)