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Summary Judgment in Personal Injury Protection Case

Jarred S. Dichek and Scott M. Simon | June 1, 2017

Jarred S. Dichek and Scott M. Simon, of the Miami office, were successful in obtaining Final Summary Judgment on three cases. In these cases, Plaintiff’s bills were the first received and the total amount billed fell below the deductible amount. The Insurer applied
the Medicare fee schedule reductions to the bills submitted from the Plaintiff and then applied them to the deductible. Plaintiff argued that per Florida Statute § 627.736, the Insurer should not have applied any reductions and should have applied 100% of the bill towards the deductible. Plaintiff argued that as a result of the misapplication of the deductible, they could not balance bill the patient for the full amount of their bill and as a result they have been damaged.

Plaintiff relied upon § 627.736(5)(a)(4) which states that a provider is prohibited from balance billing a patient in excess of the allowable amount designated by the insurer. Further, Plaintiff argued that even if the Insurer remedied the allocation at this time, it was too late because the deductible has already been exhausted.

The Insurer’s position was that no matter which way the deductible was applied, the Plaintiff would never have been entitled to benefits. Jarred argued that the deductible is extra contractual and the Insurer is only responsible for paying the $10,000.00, in benefits contracted for. Further, he argued that § 627.736(5)(a)(4) did not apply because a deductible can never be considered payment and the narrowly carved out exclusion to the statute applied in this case.

In the end, the court ruled that Plaintiff failed to present any evidence to show how his client was damaged and ruled in the Insurer’s favor.

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