Orthopedic Specialists, as Assignee of Kelli Serridge v. Allstate Insurance Company
177 So. 3d 19
Fla. Dist. Ct. App.2015Background
- Thirty-two consolidated PIP claims by medical providers against Allstate under no-fault policies.
- Question certified: whether policy language legally suffices to authorize using Medicare fee schedule limits under §627.736(5)(a)2., Fla. Stat. (2009).
- Endorsement states: any amounts payable are subject to limitations authorized by the PIP statute, including fee schedules.
- Providers contend the endorsement language is ambiguous and not a clear election to use Medicare fee schedules, citing Virtual Imaging and Kingsway.
- Trial court granted summary judgment for Allstate; Florida Supreme Court Virtual Imaging explained permissive nature of 2008 amendments.
- Court held the challenged language inherently unclear and reversed the judgment, remanding with conflict.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Is the endorsement language ambiguous about electing Medicare fee schedules? | Providers: language is ambiguous and permissive, not a clear election. | Allstate: language reserves rights and is not required to be explicit to elect the methodology. | Ambiguous; language construed in favor of providers. |
Key Cases Cited
- Virtual Imaging Servs., Inc. v. Geico Gen. Ins. Co., 141 So.3d 147 (Fla. 2013) (held insurer must clearly elect Medicare fee schedules to limit reimbursements)
- Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So.3d 63 (Fla. 4th DCA 2011) (policy must clearly elect fee-schedule method to limit reimbursement)
- N. Broward DPI v. Allstate Fire & Cas. Co., 20 Fla. L. Weekly Supp. 161a (Fla. Broward Cnty. Ct. 2012) (discussed subject-to language and incorporation of optional provisions)
- State Farm Mut. Auto. Ins. Co. v. Menendez, 70 So.3d 566 (Fla. 2011) (ambiguity analysis and construction against insurer)
- Hurt v. Leatherby Ins. Co., 380 So.2d 432 (Fla. 1980) (ambiguities construed against the drafter)
- Leslie Salt Co. v. United States, 55 F.3d 1397 (9th Cir. 1995) (shall be subject to interpreted as non-mandatory where applicable)