Supreme Court Backs Insurer On 'PIP' Medical Fees

Follow CBSMIAMI.COM: Facebook | Twitter

TALLAHASSEE (CBSMiami/NSF) – In a defeat for medical providers, a divided Florida Supreme Court on Thursday sided with Allstate Insurance Company in a dispute about fees paid to care for auto-accident victims.

The 4-3 ruling focused on the personal-injury protection insurance system and attempts by Allstate to reimburse providers under fee schedules from the Medicare program. The fee schedules involve limits on payments for services.

Providers challenged the practice, arguing that insurance policies were "ambiguous" about whether Allstate would use the fee schedules to limit reimbursements. The 4th District Court of Appeal, in a 2015 ruling that involved 32 consolidated cases, backed the providers.

But the Supreme Court majority overturned that decision Thursday, finding that Allstate's policies provided "legally sufficient notice" that the insurer would use the Medicare fee schedules. The 15-page decision, written by Justice Charles Canady and joined by Chief Justice Jorge Labarga and justices Peggy Quince and Ricky Polston, provided a detailed analysis of the policy wording and the personal-injury protection, or PIP, law.

"Allstate's PIP policy provides legally sufficient notice of Allstate's election to use the permissive Medicare fee schedules identified in (a section of state law) to limit reimbursements," Canady wrote. "The endorsement to Allstate's policy clearly and unambiguously states that '(a)ny amounts payable' for medical expense reimbursements 'shall be subject to any and all limitations, authorized by (state law), . . . including . . . all fee schedules.' When read in its context and as a whole with Allstate's policy, the plain and obvious meaning of the endorsement is that reimbursements will be made in accordance with all of the fee schedule limitations contained within (the section of state law)."

But Justice Barbara Pariente, in a dissent joined by Justice R. Fred Lewis and Senior Justice James E.C. Perry, wrote that the Supreme Court should uphold the lower-court's ruling that the Allstate policy language is "inherently unclear."

"I agree with the 4th District's explanation that the policy language including 'all fee schedules' authorized by Florida's PIP statute does not clearly and unambiguously put providers on notice that Allstate elects the Medicare fee schedule," Pariente wrote.

While the 4th District Court of Appeal sided with the providers, other courts had reached different conclusions about the policy language. In its ruling Thursday, the Supreme Court said it also was approving a 1st District Court of Appeal decision that went in favor of Allstate. The 3rd District Court of Appeal last year also ruled in favor of Allstate.

The Florida Medical Association, which represents thousands of physicians across the state, filed a friend-of-the-court brief last year urging the Supreme Court to uphold the 4th District Court of Appeal decision in favor of providers.

"The election as to which payment methodology is utilized by Allstate is critical to the medical profession and carries with it ramifications that directly affect physician reimbursements and the doctor patient relationship," the friend-of-the-court brief said.

The News Service of Florida's Jim Saunders contributed to this report.