Kingsway Amigo Insurance Co. v. Ocean Health, Inc.
2011 Fla. App. LEXIS 7184
| Fla. Dist. Ct. App. | 2011

Background

  • Kingsway insured involved in an April 2008 motor vehicle accident; policy in effect March 29–Sept 29, 2008 provided PIP benefits and 80% of medical expenses.
  • Insured assigned PIP benefits to Ocean Health for chiropractic treatments; Ocean Health billed Kingsway directly.
  • Kingsway paid 80% of 200% of the Medicare Part B fee schedule (the Part B-based method) after deductible; this amounted to less than 80% of the billed amount.
  • Statutory framework: 627.736(1)(a) requires 80% of reasonable, medically necessary expenses; 627.736(5)(a)2–5 provides a permissive alternative using Medicare Part B or other schedules; 627.7407(2) incorporates No-Fault into policies.
  • Trial court granted summary judgment for Ocean Health and certified a question of great public importance about whether a PIP insurer may use Part B schedules when the policy specifies 80% of medically necessary expenses.

Issues

Issue Plaintiff's Argument Defendant's Argument Held
May a PIP insurer use Medicare Part B schedules when the policy states 80% of medically necessary expenses? Kingsway argues insurer may select the permissive Part B method under 627.736(5)(a)2. Ocean Health argues policy language governs and the permissive method is not triggered by the policy's language requiring 80% of expenses. Negative; policy language controls and insurer cannot unilaterally adopt Part B method.

Key Cases Cited

  • Nichols, 21 So.3d 904 (Fla. 5th DCA 2009) (may limit language is permissive; policy controls when not referenced)
  • MRI Assocs. of Am., LLC v. State Farm Fire & Cas. Co., 61 So.3d 462 (Fla. 4th DCA 2011) (precision in billing requires unambiguous payment methodology)
  • Knowles v. Beverly Enters.-Fla., Inc., 898 So.2d 1 (Fla. 2004) (statutory language governs; legislative intent is central)
  • Morsani v. Major League Baseball, 790 So.2d 1071 (Fla. 2001) (statutory interpretation uses plain language and legislative intent)
  • Wright v. Auto-Owners Ins. Co., 739 So.2d 180 (Fla. 2d DCA 1999) (policy provisions may reflect greater coverage than statute)
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