Custer Medical Center v. United Automobile Insurance Co.
62 So. 3d 1086
| Fla. | 2010Background
- Masis was injured in a 2002 auto accident and treated at Custer Medical Center from Jan. 8 to Mar. 1, 2002, incurring $4,250 in charges.
- Masis submitted a PIP claim; United established a claim file and later denied benefits after scheduling medical examinations.
- Custer, as Masis’s assignee, sought reimbursement for medical expenses already incurred and billed prior to any examination.
- United asserted an affirmative defense that Masis unreasonably refused to attend a scheduled medical examination under §627.736(7), Florida Statutes (2001).
- The circuit court directed a verdict for United on the defense; the circuit court appellate division reversed and remanded for a merits trial.
- The Third District granted certiorari, quashed, and remanded to reinstate the directed verdict for United, relying on a policy provision and treating attendance as a condition precedent to coverage.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Third District correctly applied second-tier certiorari review. | Custer contends the circuit court complied with Ivey/Haines/Kaklamanos and did not depart from the essential requirements of law. | United contends the circuit court departed from essential law by improper burden-shifting and de novo review. | Quash; certiorari improper; circuit court acted within proper standards. |
| Whether attendance at a medical examination is a condition precedent to the existence of a PIP policy. | Masis’s attendance status does not make policy existence contingent. | Attendance is a condition precedent, shifting burden to Masis to prove reasonable attendance. | Held that attendance is not a condition precedent to policy existence; statutory/substantive PIP provisions control. |
| Who bears the burden to prove an insurer’s affirmative defense of unreasonable failure to attend a medical exam? | United failed to prove unreasonableness and failed to present evidence supporting the defense. | United bore the burden to plead and prove an unreasonable failure to attend. | Circuit court correctly required United to prove an affirmative defense with evidence; directed verdict improper. |
| Did the Third District improperly rely on extraneous policy language to support its ruling? | Policy language not raised below cannot be dispositive. | Policy provisions support the district’s condition-precedent theory. | District’s reliance on policy language was improper; not dispositive. |
Key Cases Cited
- Allstate Ins. Co. v. Kaklamanos, 843 So.2d 885 (Fla.2003) (certiorari standard narrows review as to procedural due process and misapplication of law)
- Ivey v. Allstate Ins. Co., 774 So.2d 679 (Fla.2000) (certiorari limited to essential requirements of law; no second appeal)
- Haines City Cmty. Dev. v. Heggs, 658 So.2d 523 (Fla.1995) (certiorari discipline and narrowing of review; not improper per se)
- Combs v. State, 436 So.2d 93 (Fla.1983) (certiorari standards; miscarriage of justice)
- Griffin v. Stonewall Ins. Co., 346 So.2d 97 (Fla.3d DCA 1977) (life-insurance context; distinguishable from auto-PIP)