United Auto. Ins. Co. v. ISOT Med. Ctr. Corp.

• Decision Date: 10 November 2021
• Docket Number: 3D21-114
• Parties: United Automobile Insurance Company, Appellant, v. ISOT Medical Center Corp., a/a/o Joseph Rodriguez, Appellee.
• Court: Florida District Court of Appeals

United Automobile Insurance Company, Appellant, v. ISOT Medical Center Corp., a/a/o Joseph Rodriguez, Appellee.

No. 3D21-114

Florida Court of Appeals, Third District

November 10, 2021

Not final until disposition of timely filed motion for rehearing.

An Appeal from the County Court for Miami-Dade County Lower Tribunal Nos. 12-1585SP, 20-107AP, Lawrence D. King, Judge.

Michael J. Neimand, for appellant.

Law Office of Chad A. Barr, P.A., and Chad A. Barr and Dalton L Gray (Altamonte Springs), for appellee.

Before LOGUE, LINDSEY and HENDON, JJ.

HENDON, J.

United Automobile Insurance Company ("UAIC") appeals from a final judgment in favor of ISOT Medical Center Corporation a/a/o Joseph Rodriguez ("ISOT"). We affirm.

In March 2009, Joseph Rodriguez was injured in an auto accident. Rodriguez was insured by UAIC, with a $1, 000 policy deductible. He assigned his UAIC benefits to ISOT, which provided medical treatments and timely submitted its bills to UAIC. UAIC initially denied all charges. Upon receipt of ISOT's demand letter, UAIC allowed ISOT's bills reduced each bill to the schedule of maximum charges, ^[1] applied the first $1, 000 of the reduced charges to the $1, 000 policy deductible, and then reimbursed the remaining charges at 80% of the schedule of maximum charges.

ISOT subsequently filed suit against UAIC for breach of contract to recover further benefits owed for the medical services it rendered, alleging the underpayment of PIP benefits and seeking further reimbursement of PIP benefits and statutory interest. UAIC answered the complaint but did not assert any affirmative defenses. ISOT then filed a motion for summary judgment as to the reasonableness of its charges for dates of service March 19, 2009 to May 28, 2009. Both parties filed competing affidavits to support their motions, and the court denied ISOT's motion.

During the litigation, the Florida Supreme Court ruled that that an insurer cannot reduce a medical provider's bills to a fee schedule before applying a policy deductible. Progressive Select Ins. Co. v. Fla. Hosp. Med. Ctr., 260 So.3d 219, 226 (Fla. 2018) (holding the deductible must be applied to 100% of the charges, only afterwards reduced to the schedule of maximum charges; the insurance company does not get to reduce the charges before applying the deductible). ISOT then filed another motion for summary judgment asserting that when UAIC applied the deductible, it reduced ISOT's charges from the billed amounts to the fee schedule amounts before applying the deductible, contrary to the holding in Progressive. In so doing, ISOT argued that UAIC improperly applied the policy deductible to several charges that fell outside of the first $1, 000 of charges. Thus, once the deductible was re-calculated to be properly applied to the first $1, 000 of charges billed, a group of unpaid charges remained to which UAIC improperly applied the deductible but were not supposed to be reduced by the deductible. The summary judgment was specific to the four identified codes that are not disputed by either party as reasonable, related, or necessary and for which no prior reimbursement was previously made.

UAIC argued that ISOT was improperly seeking summary judgment as the money due ISOT for the four identified services would not then be utilized in a set-off. ISOT argued that, while UAIC previously issued the disputed reimbursements, it nevertheless failed to plead a payment defense and, furthermore, misinterpreted the rights of a set-off, specifically, that set-offs are for correcting codes or claims on an individual basis rather "mov[ing] money around from one code to another code after they reapply the deductible."

At the summary judgment hearing, ISOT contended that by accepting the amount UAIC paid for what it at the time believed were medically necessary services, ISOT was entitled to summary judgment. In other words, ISOT argued that upon proper recalculation of the deductible the four contested treatment codes should have been reimbursed by UAIC and argued its entitlement to summary judgment on this basis. UAIC responded that this failed to include the treatment that UAIC paid for but was now contesting, that occurred after March 31, 2009. UAIC agreed that it misapplied the deductible but argued at summary judgment that it is entitled to a setoff for the amount it overpaid for those treatments after March 31, 2009, relying on its expert's uncontested affidavit that those additional charges were not medically necessary or reasonable. UAIC argued that because ISOT did not state at summary judgment that it was still relying on its own expert's affidavit, which asserted that the disputed treatments were reasonable, related and necessary, UAIC's expert's testimony was unchallenged. The trial court denied...