Two Decisive Victories in the Florida Supreme Court for Clinics

Today, in Geico General Insurance Company v. Virtual Imaging Services, Inc., the Florida Supreme Court decided the issue once and for all – insurance companies may not use the “fee schedules” in limiting reimbursement to medical providers unless they state they will do so in their insurance policies. This applies to all PIP claims from 2008 onward.

If when you receive correspondence from the insurer on a claim, and the insurer suggests that it has limited reimbursement to “200% of medicare” or the “worker’s comp” fee schedule, the insurer must have placed it in the policy. Many times insurers will try to put the language in their policy and will fail because the language is not specific enough (the requirements are very strict). If you have questions about this, you should ask your PIP lawyer – we are always willing to help out clients interpret insurance policies, and we probably already have a copy of the policy handy (and have argued it in court).

The next big victory was in Merly Nunez v. Geico General Insurance Company, which came out last Thursday. It indicated that for claims made before 2013, patients did not need to go to examinations under oath (EUOs) to make a PIP claim – which means if you have PIP claims that have been denied for failure to attend an EUO for patients before 2013, the insurers cannot disclaim the loss for that reason. While previously the Custer Medical Center decision had indicated the Supreme Court did not consider EUOs part of PIP under the old statutory regime, the insurers still fought the decision, trying to argue their way around the opinion, which was really about IMEs. This leaves no doubt. Before 2013, EUOs had no place in PIP. Unfortunately, the legislature anticipated the Supreme Court’s opinion here, and because of Custer, the legislature had placed language in the 2013 statute requiring the insured to go to the EUOs. As of today, if you have an EUO request, the patient must go to obtain coverage for PIP.

The Florida Supreme Court was split 5-2 in both cases – Lewis, Perry, Labarga, Quince, and Pariente in favor of the clinics, and Polston and Canady in favor of the insurance companies (which seems to be the trend).