Geico General Insurance v. Virtual Imaging Services, Inc.
90 So. 3d 321
Fla. Dist. Ct. App.2012Background
- 2008 PIP amendment allows insurers to limit reimbursement to 200% of Medicare Part B rates; effective Jan 1, 2008.
- Insured's two MRIs were performed after the 2008 amendment, with policy date and accident occurring post-amendment.
- Appellee MRI provider billed $3,600; 80% of that equals $2,880.
- Under the 2008 amendment, 80% of 200% of Medicare Part B is $1,989.57 for these services.
- County court held for appellee but certified a question on whether insurers can limit to 80% of the fee schedule without a policy election.
- This court affirmed Geico Indemnity Co. v. Virtual Imaging Servs. and certified a related question to the Florida Supreme Court.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| May insurer use the PIP fee schedule without policy election? | Virtual Imaging: policy lacks explicit election to use the fee schedule. | Geico: statute permits fee schedule use; no election required. | Yes; fee schedule incorporated by law and by reference. |
| Are there two reimbursement methodologies under §627.736? | Two methodologies exist: 80% of reasonable expenses or 80% of 200% of Part B. | Only one method satisfies mandatory reimbursement. | There is only one reimbursement method under the statute. |
| Does the policy provide greater coverage than the PIP statute? | Policy may offer more favorable terms than the statute. | No greater coverage than the PIP statute. | No; policy does not provide greater coverage. |
| Is the PIP fee schedule incorporated by law and by reference? | Not necessary to amend policy; statute suffices. | Incorporation by law and by reference makes schedule binding. | Yes; incorporated by law and by reference. |
| Does requiring an explicit policy election contradict the Legislature’s intent? | Election requirement preserves insurer control. | Election not required; statute makes schedule binding. | Election not required; schedule binding under law. |
Key Cases Cited
- Holy Cross Hosp. v. Jewell, 961 So.2d 335 (Fla. 2007) (pre-fee schedule authority allowing contract-based rates)
- Jewell, 862 So.2d 79 (Fla. 2007) (insurer may contract for agreed rates; reasonableness factors used)
- Nichols, 21 So.3d 904 (Fla. 5th DCA 2009) (policy vs permissive statute timing; policy binding when statute permissive)
- Kingsway Mut. Ins. Co. v. Ocean Health, Inc., 63 So.3d 67 (Fla. 4th DCA 2010) (policy vs permissive statute with greater-coverage issue)
- Geico Indemnity Co. v. Virtual Imaging Servs., Inc., 79 So.3d 55 (Fla. 3d DCA 2011) (split decision; fee schedule incorporated; ambiguity debate)