Med. Ctr. of the Palm Beaches v. USAA Cas. Ins. Co.

• Decision Date: 31 August 2016
• Docket Number: No. 4D14–3580.,4D14–3580.
• Parties: MEDICAL CENTER OF the PALM BEACHES d/b/a Central Palm Beach Physicians & Urgent Care, Inc. a/a/o Carmen Santiago, Appellant, v. USAA CASUALTY INSURANCE COMPANY, Appellee.
• Court: Florida District Court of Appeals

202 So.3d 88

MEDICAL CENTER OF the PALM BEACHES d/b/a Central Palm Beach Physicians & Urgent Care, Inc. a/a/o Carmen Santiago, Appellant,

v.USAA CASUALTY INSURANCE COMPANY, Appellee.

No. 4D14–3580.

District Court of Appeal of Florida, Fourth District.

Aug. 31, 2016.

Marlene S. Reiss of the Law Offices of Marlene S. Reiss, Esq., P.A., Miami, for appellant.

Douglas H. Stein of Seipp, Flick & Hosley, LLP, Coral Gables, for appellee.

Russel M. Lazega and Yasmin Gilinsky of Florida Advocates, Dania Beach, for Amici Curiae Health Management Associates, St. Vincent's Medical Center, and Tenet Florida, Inc.

Maria Elena Abate and Raquel Moya of Colodny Fass, P.A., Sunrise, for Amici Curiae Property Casualty Insurers Association of America and the Personal Insurance Federation of Florida.

LEVINE

, J.

The issue presented is whether a qualified medical provider must determine that an emergency medical condition exists for benefits to exceed $2,500 under Florida's PIP statute. Stated in another way, if either there has been no determination of whether the insured has an emergency medical condition or there has been a determination that the insured does not have an emergency medical condition, would the benefits under PIP be limited to $2,500. We find that the statute requires a determination of an emergency medical condition for the benefits to be up to $10,000. Further, we find that if either there is no determination of whether the insured has an emergency medical condition or there has been a determination that the insured does not have an emergency medical condition, then the benefits would be limited to $2,500.

Carmen Santiago, the insured, was injured in a motor vehicle accident. She went to an urgent care center due to pain in her cervical region and right shoulder. The doctor referred her to appellant for physical therapy. Appellant then submitted bills for payment to appellee USAA, the insurer, but USAA provided no additional payment, explaining that, pursuant to section 627.736(1)(a)(4), Florida Statutes

, $2,500 had already been reimbursed under the policy. USAA requested that appellant provide “the determination of the patient's emergency medical condition by a provider authorized” so that USAA could make any additional reimbursement decisions.

Appellant sued USAA for breaching the insurance contract by failing to issue full payment for the medical treatment appellant provided. Subsequently, appellant sent USAA a note from Dr. Chang, the insured's treating physician, which stated that he considered the insured to have an emergency medical condition. Upon receipt of this documentation, USAA paid all outstanding charges under the policy until the limits were reached. USAA moved for summary judgment, which the trial court granted, finding that the provisions of section 627.736(1)(a)(3)

-(4) limit medical benefits to $2,500 until there is a determination that the insured had an emergency medical condition. The trial court also determined USAA properly requested that appellant provide information regarding the insured's medical condition, pursuant to section 627.736(6)(b), to justify additional reimbursement. The trial court disagreed with appellant that USAA waived any defenses because it paid the medical reimbursement after the suit was filed, and determined there was no confession of judgment because USAA did not wrongfully withhold payment.

The trial court also certified a question of great public importance, which we rephrase as follows:

IN AN ACTION BY AN ASSIGNEE FOR NO–FAULT INSURANCE BENEFITS UNDER A POLICY OF MOTOR VEHICLE INSURANCE, ARE BENEFITS ABOVE $2,500 ONLY AVAILABLE WHERE THERE HAS BEEN A DETERMINATION BY A MEDICAL PROVIDER AUTHORIZED BY STATUTE THAT AN EMERGENCY MEDICAL CONDITION EXISTS, AS DEFINED IN THE FLORIDA NO–FAULT LAW?

Appellant appeals the decision of the trial court.

Our “standard of review is de novo, because this is an appeal from a summary judgment and, also, because the substantive question posed is a legal question of statutory construction.” Progressive Auto Pro Ins. Co. v. One Stop Med., Inc., 985 So.2d 10, 12 (Fla. 4th DCA 2008)

.

The Florida Motor Vehicle No–Fault Law requires that automobile insurers provide personal injury protection “to a limit of $10,000 in medical and disability benefits ... resulting from bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle.” § 627.736(1), Fla. Stat. (2013)

.

Section 627.736(1)(a)(3)

-(4), Florida Statutes (2013), states,

3. Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. up to $10,000 if a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464 has determined that the injured person had an emergency medical condition.

Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. is limited to $2,500 if any provider listed in subparagraph 1. or subparagraph 2. determines that the injured person did not have an emergency medical condition.

(emphasis added). An emergency medical condition is

a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(a) Serious jeopardy to patient health.

(b) Serious impairment to bodily functions.

(c) Serious dysfunction of any bodily organ or part.

§ 627.732(16), Fla. Stat. (2013)

.

“It is a fundamental principle of statutory interpretation that legislative intent is the ‘polestar’ that guides this Court's interpretation.” Borden v. East–European Ins. Co., 921 So.2d 587, 595 (Fla.2006)

. The best method to determine the intent of the legislature is to “look to the actual language used in the statute.” Daniels v. Fla. Dep't of Health, 898 So.2d 61, 64 (Fla.2005). Clearly, “[w]hen the statute is clear and unambiguous, courts will not look behind the statute's plain language for legislative intent or resort to rules of statutory construction to ascertain intent.” Id. However, where the statute is ambiguous, the court “may resort to the rules of statutory construction, which permit [the court] to examine the legislative history to aid in [the] determination regarding legislative intent.”

Diamond Aircraft Indus., Inc. v. Horowitch, 107 So.3d 362, 367 (Fla.2013)

. When construing different parts of a statute, “[i]t is axiomatic that all parts of a statute must be read together in order to achieve a consistent whole. Where possible, courts must give full effect to all statutory provisions and construe related statutory provisions in harmony with one another.” Knowles v. Beverly Enterprises–Florida, Inc., 898 So.2d 1, 6 (Fla.2004) (quoting Forsythe v. Longboat Key Beach Erosion Control Dist., 604 So.2d 452, 455 (Fla.1992) ).

Appellant claims that the $2,500 statutory limit applies only when a statutorily authorized provider affirmatively determines that there is no emergency medical condition. USAA, conversely, argues that the $2,500 limit applies unless an authorized medical provider affirmatively determines that there is an emergency medical condition and notifies the insurer of that condition.

The statute addresses the situation where there has been an affirmative determination of an emergency medical condition, authorizing up to $10,000. § 627.736(1)(a)(3), Fla. Stat

. The statute also addresses the situation where there has been an affirmative determination of no emergency medical condition, authorizing up to only $2,500. § 627.736(1)(a)(4), Fla. Stat. However, nowhere in the statute does it address the situation where no determination of emergency medical condition has been made. We therefore find the statute to be ambiguous, compelling us to resort to other methods to determine the intent of the legislature. See

W. Fla. Reg'l Med. Ctr., Inc. v. See, 79 So.3d 1, 9 (Fla.2012).

We read the two provisions of the statute in para materia. “The canon is ... based upon a realistic assessment of what the legislature ought to have meant. It rests on two sound principles: (1) that the body of the law should make sense, and (2) that it is the responsibility of the courts, within the permissible meanings of the text, to make it so.” Antonin Scalia & Bryan A. Garner, Reading Law: The Interpretation of Legal Texts 252 (2012).

The case of Robbins v. Garrison Property & Casualty Insurance Co., 809 F.3d 583 (11th Cir.2015)

, is most instructive. In that case, two separate plaintiffs proceeded with a PIP claim exceeding $2,500 where no medical provider had made any determination regarding whether each insured's injury was “an emergency medical condition.” The court in Robbins recognized that both the insurer and the insureds were asking the court to impermissibly modify the statute. The insurer asked the court “to read into the statute an affirmative obligation on the part of the insured to obtain a medical provider's determination one way or the other about whether the condition was an emergency in order to receive any benefits at all.” Id. at 586. But the court refrained from doing so because “that obligation is not in the statute and we cannot add it.” Id.; see also

B.C. v. Fla. Dep't of Children & Families, 887 So.2d 1046, 1052 (Fla.2004) (“[W]e [are not] permitted to add to a statute words that were not placed there by the Legislature.”); State v. City of Fort Pierce, 88 So.2d 135, 137 (Fla.1956) (“It is not the province of this Court to rewrite the acts of the Legislature.”). The insureds in Robbins asked the court to read subparagraphs (1)(a)(3) and (1)(a)(4) out of the statute, saying they “essentially cancel[led] each other out,” resulting in a pre-existing limit of $10,000 where no determination of an emergency is made. 809 F.3d at 587. But the court also...