GEICO INDEMNITY COMPANY
v.
AFFINITY HEALTHCARE CENTER AT WATERFORD LAKES, PL A/A/O ERNST PEREIRA
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.
A health care provider's deductible must be subtracted from total medical charges before applying reimbursement limitations, and the insurer must pay 80% of 200% of the applicable fee schedule rather than 100% of the billed amount when the billed amount exceeds that threshold.
[1] A health care provider's deductible must be subtracted from the provider's total medical charges before any reimbursement limitation is applied.
[2] When a health care provider's billed amount exceeds 80% of 200% of the applicable fee schedule, an insurer must pay 80% of 200% of the applicable fee schedule rather than…
Previewing 2 of 3 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“There is nothing in the applicable statute or Geico's policy that allows it to pay 80 percent of the billed amount. It must either pay the amount allowed based on the applicable fee schedule (80 percent of 200 percent) or, if the billed amount is less than the amount allowed, it is to be paid in full.”
Court's explanation of the proper reimbursement calculation method
Affinity Healthcare Center filed suit against GEICO Indemnity Company seeking reimbursement of additional PIP benefits under GEICO's insurance contrac…
The full statement of facts, procedural history, and disposition for this case are member content.
Join FLexlaw to unlock all legal intelligence© FLexlaw, Inc. — AI-generated enrichments are proprietary. All rights reserved.
Explore caselaw by topic → Browse Summary Final Judgment cases and more on FLexlaw
IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA
FIFTH DISTRICT
NOT FINAL UNTIL TIME EXPIRES TO
FILE MOTION FOR REHEARING AND
DISPOSITION THEREOF IF FILED
GEICO INDEMNITY COMPANY, Appellant, v. Case No. 5D21-184 LT Case No. 2017-SC-12824-O
AFFINITY HEALTHCARE CENTER AT
WATERFORD LAKES, PL A/A/O
ERNST PEREIRA, Appellee. ________________________________/ Opinion filed March 25, 2022 Appeal from the County Court for Orange County, David Johnson, Judge. Rebecca Delaney and Scott W. Dutton, of Dutton Law Group, PA, Tampa, for Appellant. Chad A. Barr, of Chad Barr Law, Altamonte Springs, for Appellee.
PER CURIAM.
2 Appellee, Affinity Healthcare Center at Waterford Lakes, PL, a/a/o Ernst Pereira, (“Affinity”), filed suit against Appellant, Geico Indemnity Company, (“Geico”), seeking reimbursement of additional personal injury protection (PIP) benefits pursuant to Geico's contract with its insured, Ernst Pereira. The county court entered summary final judgment in favor of Affinity in March 2018. Upon motion, the circuit court stayed the appeal of the county court's order pending resolution of other appeals in cases dealing with similar issues. This court lifted that stay on February 9, 2022.1 Co. v. Fla. Hosp. Med. Ctr., 260 So. 3d 219, 223 (Fla. 2018) (“A plain reading of the statutory provisions makes clear that the deductible must be subtracted from the provider’s charges before the reimbursement limitation is applied.”). Second, we conclude that the trial court erred in requiring Geico to pay 100% 1 This appeal was transferred from the circuit court to this court due to a jurisdictional change which took effect January1, 2021. See Ch. 20-61, § 3, Laws of Fla. (amending § 26.012(1), Florida Statutes).
3 of Affinity's billed amount where the billed amount was more than 80% of 200% of the applicable fee schedule. Although the trial court properly rejected Geico's argument that it was only required to pay 80% of the billed amount, it should have ordered Geico to pay 80% of 200% of the applicable fee schedule. See Hands On Chiropractic PL v. Geico Gen. lns. Co., 327 So. 3d 439, 443 (Fla. 5th DCA 2021) (“There is nothing in the applicable statute or Geico’s policy that allows it to pay 80 percent of the billed amount. It must either pay the amount allowed based on the applicable fee schedule (80 percent of 200 percent) or, if the billed amount is less than the amount allowed, it is to be paid in full.”). Finally, we conclude that Geico's argument that Affinity failed to comply with conditions precedent to filing suit was not preserved below. See Saavedra v. Universal Prop. & Cas. Ins. Co., 314 So. 3d 729, 730 (Fla. 5th DCA 2021) (“Pursuant to rule 1.120(c), in denying that conditions precedent were met, a defendant is required to ‘identify both the nature of the conditions precedent and the nature of the alleged noncompliance or nonoccurrence.’”). AFFIRMED, in part; REVERSED in part; REMANDED for further proceedings consistent with this opinion. LAMBERT, C.J., EVANDER and COHEN, JJ., concur.
Cases With Similar Vibessemantic neighbors from the corpus
Citator
Authorities Cited
- Progressive Select Ins. Co. v. Fla. Hosp. Med. Ctr., 260 So. 3d 219 (Fla. 2018)