92 So. 3d 871
Fla. Dist. Ct. App.2012Background
- Florida’s PIP statute 627.736(5)(b)1.c. relieves payment for claims where someone knowingly submits a false or misleading statement; “knowingly” is defined by 627.732(10).
- Chiropractic One billed State Farm for 19 insureds’ PIP benefits and assigned those benefits to Chiropractic One.
- State Farm withheld benefits and filed a declaratory judgment action seeking relief from paying the challenged charges.
- Trial court entered multiple summary judgments finding Chiropractic One knowingly submitted false/misleading claims and that no PIP benefits were owed for the insureds’ charges.
- The appellate court interpreted 627.736(5)(b)1.c. to invalidate both the specific charges and the entire claim, but did not decide on extending the rule to all pre/post-billing related to the same insured.
- Court affirmed the final judgment, leaving for another day whether the rule applies to pre/post-billing across all time.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Scope of 627.736(5)(b)1.c. | Chiropractic One: only the specific false charge is disallowed. | State Farm: the entire claim and related charges are invalid. | Invalidates the claim and related charges; does not extend to all time beyond the case. |
| Role of 4(b) safe harbor in ongoing investigation. | Appellant argues 4(b) requires continuing investigation of each claim. | Insurer may rely on 4(b) as a safe harbor and need not indefinitely investigate. | 4(b) is a safe harbor; does not mandate continued investigation after misconduct. |
| Consequence of misconduct on PIP benefits. | Chiropractic One contends some benefits may remain for properly charged items. | State Farm argues all related benefits are forfeited due to misconduct. | Court upheld denial of PIP benefits for the challenged charges. |
Key Cases Cited
- Florida Med. & Injury Ctr., Inc. v. Progressive Express Ins. Co., 29 So.3d 329 (Fla. 5th DCA 2010) (context of PIP complexity and legislative intent to curb fraud)
- January v. State Farm Mut. Ins. Co., 838 So.2d 604 (Fla. 5th DCA 2003) (30-day investigation safe harbor under §627.736(4)(b))
- United Auto. Ins. Co. v. Rodriguez, 808 So.2d 82 (Fla. 2001) (penalties if payment after the investigative period)
- Regional MRI of Orlando, Inc. v. Nationwide Mut. Fire Ins. Co., 884 So.2d 1102 (Fla. 5th DCA 2004) (fraud and PIP billing concerns in Fifth District)
- Sandoro v. HSBC Bank, 55 So.3d 730 (Fla. 2d DCA 2011) (de novo review of final summary judgments)
- Servedio v. U.S. Bank Nat’l Ass’n, 46 So.3d 1105 (Fla. 4th DCA 2010) (statutory interpretation in context of PIP/claims)
- Quarantello v. Leroy, 977 So.2d 648 (Fla. 5th DCA 2008) (statutory interpretation in Florida Fifth District)