Sendy Enivert v. Progressive Select Insurance Company
809 F.3d 583
| 11th Cir. | 2015Background
- Florida amended its Motor Vehicle No-Fault Law in 2012 to tie PIP medical-benefit limits to whether a listed medical provider determined the insured had an "emergency medical condition."
- The statute provides up to $10,000 if a listed provider determines an emergency medical condition, and limits benefits to $2,500 if a listed provider determines there was not an emergency. The statute is silent on what limit applies if no provider made any determination.
- Robbins and Enivert, insureds in separate 2013 auto-accident cases, sought reimbursement without submitting any provider determination; their insurers (Garrison and Progressive) limited payments to $2,500.
- Both plaintiffs brought putative class actions seeking declaratory and injunctive relief and full $10,000 PIP benefits; district courts dismissed both complaints under Rule 12(b)(6).
- The Eleventh Circuit consolidated the appeals and reviewed de novo, applying Florida rules of statutory interpretation and legislative history to resolve the statutory ambiguity.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether § 627.736 requires a provider determination before the $10,000 PIP limit applies | Robbins/Enivert: If no provider determined there was "no emergency," the preexisting $10,000 cap remains available | Garrison: $10,000 applies only when a listed provider determines an emergency; Progressive: without any determination, statute provides no benefits | Court: $10,000 is available only if a listed provider determines an emergency; otherwise the limit is $2,500 |
| Whether the statute requires insureds to obtain a provider determination to receive any PIP benefits | Plaintiffs: Not asserted — they seek $10,000 absent a determination | Progressive: Insured must obtain an affirmative provider determination (either way) to receive benefits | Court: No implied affirmative duty; but legislative intent limits higher benefits absent a provider determination |
| Whether subparagraphs (1)(a)(3) and (1)(a)(4) cancel each other, leaving $10,000 intact | Plaintiffs: The two subsections effectively negate each other and leave the prior $10,000 cap | Defendants: Subsections create an either/or scheme that restricts benefits | Court: Rejects plaintiffs' negation theory; reads sections in harmony per legislative intent to curb fraud |
| Whether insurers violated § 627.736 by paying only $2,500 where no provider determination was submitted | Plaintiffs: Insurers wrongfully limited benefits to $2,500 | Insurers: Limiting to $2,500 was proper absent a provider determination of emergency | Court: Insurers acted consistently with statute and legislative purpose; dismissal affirmed |
Key Cases Cited
- Belanger v. Salvation Army, 556 F.3d 1153 (11th Cir. 2009) (standard of review for Rule 12(b)(6) and de novo statutory interpretation)
- Allen v. USAA Cas. Ins. Co., 790 F.3d 1274 (11th Cir. 2015) (apply state statutory interpretation rules when differing)
- Diamond Aircraft Indus., Inc. v. Horowitch, 107 So. 3d 362 (Fla. 2013) (when statute ambiguous, consult legislative history)
- Am. Home Assurance Co. v. Plaza Materials Corp., 908 So. 2d 360 (Fla. 2005) (avoid readings that render a coequal provision nugatory)
- White v. State, 714 So. 2d 440 (Fla. 1998) (legislative staff analyses as a touchstone of collective legislative will)
- Byrd v. Richardson–Greenshields Sec., Inc., 552 So. 2d 1099 (Fla. 1989) (honor obvious legislative intent and policy)