STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, PETITIONER,
v.
HYMA MEDICAL CENTER, INC., AS ASSIGNEE OF SADYS LOPEZ, RESPONDENT
AI-generated. These summaries, headnotes, and key points are machine-generated and may contain errors or omissions. Always verify against the full opinion text below. Not legal advice.
State Farm petitioned for second-tier certiorari challenging a summary judgment in favor of Hyma Medical Center for unpaid PIP benefits. The court granted the petition, holding that the lower court applied the wrong statutory provision—using the withdrawal framework of §627.736(7)(a) instead of the denial framework of §627.736(4)(b)—and remanded for proceedings under the correct statute.
The court held that §627.736(7)(a) does not apply to denial cases; it applies only to withdrawal cases. Because this was a denial case governed by §627.736(4)(b), the lower court's application of §627.736(7)(a)'s requirement that a physician's affidavit be 'factually supported' was improper, and the summary judgment cannot be upheld on a right-for-wrong-reason basis.
[1] A reviewing physician's affidavit must be factually supported by examination and treatment records when an insurer seeks to withdraw future personal injury protection (PI…
[2] The statutory requirement that a reviewing physician's report be factually supported by examination and treatment records applies to "withdrawal" cases, not "denial" case…
Previewing 2 of 5 headnotes on this case. FLexlaw’s editorially structured points of law — every proposition, pinpointed — are reserved for members.
Join FLexlaw to unlock all legal intelligence“This case is a "denial" case, where the insurer never paid any of the claims. A denial case is governed by paragraph 627.736(4)(b), Florida Statutes.”
Establishes the critical distinction between denial and withdrawal cases, which determines which statutory provision applies.
Previewing 1 of 3 key quotes on this case — the court’s exact language, pinpointed for members.
Join FLexlaw to unlock all legal intelligenceSadys Lopez, a State Farm PIP-insured policyholder, was injured in an automobile accident and obtained treatment from Hyma Medical Center, to whom she…
The full statement of facts, procedural history, and disposition for this case are member content.
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This is a petition for second-tier certio-rari in a case involving the denial of personal injury protection (“PIP”) benefits. We grant the petition.
Sadys Lopez is an insured under PIP coverage issued by petitioner State Farm Mutual Automobile Insurance Company. According to the amended complaint, she was in an automobile accident and obtained treatment from Hyma Medical Center, Inc., to whom she assigned her PIP benefits.
Hyma submitted its medical bills to State Farm. State Farm paid nothing, taking the position that the bills were not reasonable, related, or necessary.
Hyma filed suit in county court and the court entered summary judgment in Hyma’s favor. State Farm appealed to the appellate division of the circuit court. In its answer brief, Hyma conceded that the reasons which had led to the entry of the county court judgment were invalid.
Hyma argued, however, that the judgment could be upheld on a “right-for-wrong-reason” basis. See Dade County School Board v. Radio Station WQBA, 731 So.2d 638, 644 (Fla.1999). Hyma argued that the affidavit submitted by State Farm’s reviewing physician was invalid. Hyma contended that the reviewing physician’s affidavit was not “factually supported by the examination and treatment records [of the insured].” § 627.736(7)(a), Florida Statutes (2008). The appellate division affirmed without opinion and State Farm has petitioned for second-tier certio-rari.
This petition raises one of the issues addressed by this court’s recent opinion in United Automobile Ins. Co. v. Santa Fe Medical Center, 21 So.3d 60 (Fla. 3d DCA 2009) (en banc). This case is a “denial” case, where the insurer never paid any of the claims. A denial case is governed by paragraph 627.736(4)(b), Florida Statutes. As explained in Santa Fe, paragraph (4)(b) “pertains to circumstances where ‘the insurer has either reduced, omitted, or declined’ payment of PIP claims that are reasonable, necessary, and related .... ” 21 So.3d at 63. See also Partners in Health Chiropractic v. United *701 Automobile Ins. Co., 21 So.3d 858 (Fla. 3d DCA 2009).
By contrast, paragraph 627.736(7)(a), Florida Statutes, is applicable in a “withdrawal” case. In a withdrawal case the insurer has made payments but then seeks to withdraw all future payments for the same injury. In that situation paragraph (7)(a) “sets forth the necessary requirements that an insurer must satisfy before it may withdraw future PIP benefits.” Santa Fe, 21 So.3d at 63.
We conclude that the circuit court appellate division departed from the essential requirements of law. The appellate division accepted Hyma’s argument that State Farm’s reviewing physician’s affidavit did not comply with that part of paragraph (7)(a) that requires the reviewing physician’s report to be “factually supported by the examination and treatment records[.]” The problem is that the statutory language just quoted applies to a withdrawal case which is governed by paragraph (7)(a), but this is a denial case. Paragraph (7)(a) is inapplicable. That being so, the summary judgment cannot be upheld on the right-for-wrong-reason analysis offered by Hyma.
We therefore quash the opinion of the appellate division of the circuit court. The case must be returned to the county court for further proceedings under paragraph 627.736(4)(b), Florida Statutes.
Petition granted.
Cases With Similar Vibessemantic neighbors from the corpus
Citator
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David Shaw, David G. Shaw D.C., P.A. v. State Farm Fire & Cas. Co., 37 So. 3d 329 (Fla. 5th DCA 2010)…ent of the insured’s rights and benefits under the insured’s insurance policy does not deprive State Farm of the right and ability to contest the validity of those bills and refuse payment. See State Farm Mut. Auto. Ins. Co. v. Hyma Med. Ctr., Inc., 22 So. 3d 699, 700 (Fla. 3d DCA 2009); United Auto. Ins. Co. v. Santa Fe Med. Ctr., 21 So. 3d 60 (Fla. 3d DCA 2009) (“[T]he thirty-day period for the payment of PIP benefits contained in section 627.736(4)(b) only applies [*341] to the payment of benefits that ar…
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State Farm Mut. Auto. Ins. Co. v. Reidy Williams, 824 F.3d 1311 (11th Cir. 2014)…al case, the essential difference between a withdrawal of benefits and denial of benefits is that, in a withdrawal, the insurer first has made a payment but refused to make more payments. State Farm Mut. Auto. Ins. Co. v. Hyma Med. Ctr., Inc., 22 So. 3d 699, 701 (Fla. 3d Dist. Ct. App. 2009); see also United Auto. Ins. Co. v. Santa Fe Med. Ctr., 21 So. 3d 60, 65 (Fla. 3d Dist. Ct. App. 2009) (en banc); State Farm Mut. Auto. Ins. Co. v. Rhodes & Anderson, D.C., P.A., 18 So. 3d 1059, 1063-64…
Authorities Cited
- Dade Cnty. Sch. Bd. v. Radio Station Wqba, 731 So. 2d 638 (Fla. 1999)
- United Auto. Ins. Co. v. Santa FE Med. Ctr., 21 So. 3d 60 (Fla. 3d DCA 2009)
- P'rs IN Health Chiropractic v. United Auto. Ins. Co., 21 So. 3d 858 (Fla. 3d DCA 2009)