202 So. 3d 88
Fla. Dist. Ct. App.2016Background
- Carmen Santiago was injured in a vehicle accident and treated at urgent care, then referred to appellant (assignor) for physical therapy.
- Appellant billed USAA (insurer) for PIP benefits; USAA paid $2,500 and refused further payment pending a provider’s determination whether an "emergency medical condition" (EMC) existed under Fla. Stat. § 627.736.
- Appellant sued for breach of contract; after suit was filed appellant produced a treating physician’s note diagnosing an EMC and USAA then paid additional charges up to policy limits.
- The trial court granted summary judgment for USAA, holding that payment above $2,500 requires an authorized provider’s affirmative EMC determination and that USAA properly requested medical documentation under § 627.736(6)(b).
- The court certified the controlling question of public importance about whether benefits over $2,500 require a provider’s EMC determination; the district court reviews statutory construction de novo.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether PIP benefits above $2,500 require an authorized provider’s determination that an EMC exists | Appellant: $2,500 cap applies only when a provider affirmatively determines there is no EMC; absent any determination, $10,000 is available | USAA: Benefits are limited to $2,500 unless an authorized provider affirmatively determines an EMC and insurer is notified | Court: Benefits above $2,500 are available only when an authorized provider has determined an EMC exists; absent such a determination (or if provider determines no EMC), limit is $2,500 |
| Whether insurer may request written medical documentation before paying over $2,500 | Appellant: Demand letter for full payment was timely; insurer’s later request did not bar recovery | USAA: Properly requested medical report under § 627.736(6)(b) and payment over $2,500 may await that documentation | Court: Insurer properly requested a written report under § 627.736(6)(b); appellant’s demand was premature without complying with that request |
| Whether insurer’s later payment after suit waived defenses or constituted confession of judgment | Appellant: Post-suit payment waived defenses/confessed judgment | USAA: Payment after receiving EMC determination did not waive defenses or confess judgment | Court: No waiver or confession; USAA did not wrongfully withhold payment once it requested documentation and later received EMC determination |
| Statutory interpretation method: plain meaning vs. legislative intent | Appellant: Read subparagraphs to allow $10,000 absent any determination | USAA: Read statute to require affirmative EMC determination to unlock $10,000 | Court: Statute ambiguous on no-determination scenario; read provisions in pari materia and relied on legislative history and Robbins v. Garrison to require provider determination for >$2,500 |
Key Cases Cited
- Robbins v. Garrison Prop. & Cas. Ins. Co., 809 F.3d 583 (11th Cir. 2015) (held § 627.736 limits insurer’s PIP obligation to $2,500 unless an authorized provider determines an EMC; looked to legislative history)
- Progressive Auto Pro Ins. Co. v. One Stop Med., 985 So.2d 10 (Fla. 4th DCA 2008) (stated standard of review for summary judgment and legal questions is de novo)
- W. Fla. Reg’l Med. Ctr., Inc. v. See, 79 So.3d 1 (Fla. 2012) (statutory ambiguity permits resort to legislative history)
- Borden v. East-European Ins. Co., 921 So.2d 587 (Fla. 2006) (legislative intent is the guiding principle in statutory interpretation)