Government Employees Insurance Co. v. Jorge E. Martinez
21-10297
| 11th Cir. | Nov 5, 2021Background
- Quality Diagnostic Health Care, Inc. (a Florida clinic) submitted PIP claims to GEICO for patient exams and physical-therapy services after auto accidents.
- Defendants (physicians Keane and Queral, massage therapist Viera, and others) were alleged to have caused submission of upcoded invoices and to have represented that PT services were provided or directly supervised by a licensed physician.
- Evidence undisputed at summary judgment: billed services were upcoded; physical-therapy services were performed by an unsupervised massage therapist not licensed as a physical therapist; invoices falsely represented physician provision/supervision.
- GEICO sought recovery of approximately $145,000 already paid and a declaration that remaining ~$79,000 in claims were non-reimbursable; asserted claims for declaratory relief, common-law fraud, unjust enrichment, and FDUTPA violations.
- The district court granted GEICO summary judgment on fraud, unjust enrichment, FDUTPA, and declaratory relief; it denied Defendants’ Rule 59(e) motion to alter or amend the judgment. The Eleventh Circuit affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Common-law fraud (reliance/materiality) | GEICO: Defendants knowingly submitted false/upcoded bills; GEICO justifiably relied and was harmed | Defs: GEICO knew or should have known falsities from records; payment indicates non-materiality | Reliance was justified; falsity not "obvious" from a cursory review; summary judgment for GEICO on fraud |
| Unjust enrichment | GEICO: Paid benefits conferred a benefit to Defendants they were not legally entitled to keep | Defs: Payments were made to Quality only, not individual defendants (argued late) | Payments were benefits not legally due; unjust enrichment judgment affirmed |
| FDUTPA (deceptive/unfair practices) | GEICO: Upcoding and false supervision statements were deceptive and caused GEICO's damages | Defs: GEICO had notice of deception; reliance required | FDUTPA claim need not show actual reliance; no evidence GEICO had adequate notice; summary judgment for GEICO |
| Rule 59(e) motion (new argument re: supervision) | Defs: Claimed post-judgment that PT services were indirectly supervised by Dr. Keane | GEICO: Argument could have been raised earlier; law forecloses reimbursement for PT by massage therapists regardless of supervision here | Denial affirmed: argument raised too late and Beacon/Florida law preclude reimbursement for PT by massage therapists without direct on-site supervision |
Key Cases Cited
- Gandy v. Trans World Comput. Tech. Grp., 787 So.2d 116 (Fla. Dist. Ct. App. 2001) (elements of common-law fraud)
- Besett v. Basnett, 389 So.2d 995 (Fla. 1980) (reliance rule; falsity must be "obvious" to bar reliance)
- Schrader v. Prudential Ins. Co., 280 F.2d 355 (5th Cir. 1960) (insurer entitled to rely on insured's representations absent directing circumstances)
- Beacon Healthcare Ctr. Inc. v. Geico Gen. Ins. Co., 298 So. 3d 1235 (Fla. Dist. Ct. App. 2020) (PT services by massage therapists not reimbursable under Florida No‑Fault Law)
- Virgilio v. Ryland Grp., Inc., 680 F.3d 1329 (11th Cir. 2012) (elements of unjust enrichment under Florida law)
- State Farm Fire & Cas. Co. v. Silver Start Health & Rehab Inc., 739 F.3d 579 (11th Cir. 2013) (unjust enrichment where benefits were not legally owed)
- Dolphin LLC v. WCI Cmtys., Inc., 715 F.3d 1243 (11th Cir. 2013) (elements of a FDUTPA claim)
- Arthur v. King, 500 F.3d 1335 (11th Cir. 2007) (standard for Rule 59(e) — cannot relitigate or raise arguments that could have been earlier)
- Holloman v. Mail‑Well Corp., 443 F.3d 832 (11th Cir. 2006) (summary judgment legal standard)