IN THE FLORIDA SUPREME COURT

GEICO GENERAL INSURANCECOMPANY,

Petitioner,

vs. Case No. SC12-905

VIRTUAL IMAGING SERVICES,INC., as assignee of Maria Tirado, e3

Respondent.

APPEAL ON CERTIFIED QUESTION

ST PETE MRI'S AMICUS CURIAE BRIEFIN SUPPORT OF RESPONDENT

David M. Caldevilla and Michael R. Bray, de la Parte & Gilbert, P.A.,Post Office Box 2350, Tampa, FL 33601-2350, Telephone: (813) 229-2775

Craig E. Rothburd, Craig E. Rothburd, P.A.,800 W. De Leon Street, Tampa, FL 33606-2722, Telephone: (813) 251-8800

Scott R. Jeeves, The Jeeves Law Group, P.A.,954 First Avenue North, St. Petersburg, FL 33705, Telephone: (727) 894-2929

Lorca J. Divale, The Divale Law Group, P.A.,P.O. Box 22347 St. Petersburg, FL 33742, Telephone: (727) 321-5646

COUNSEL FOR ST. PETE MRI

h IN THE FLORIDA SUPREME COURT

GEICO GENERAL INSURANCECOMPANY,

Petitioner,

vs. Case No. SC12-905

VIRTUAL IMAGING SERVICES,INC., as assignee of Maria Tirado,

Respondent.

APPEAL ON CERTIFIED QUESTION

ST PETE MRI'S AMICUS CURIAE BRIEFIN SUPPORT OF RESPONDENT

David M. Caldevilla and Michael R. Bray, de la Parte & Gilbert, P.A.,Post Office Box 2350, Tampa, FL 33601-2350, Telephone: (813) 229-2775

Craig E. Rothburd, Craig E. Rothburd, P.A.,800 W. De Leon Street, Tampa, FL 33606-2722, Telephone: (813) 251-8800

Scott R. Jeeves, The Jeeves Law Group, P.A.,954 First Avenue North, St. Petersburg, FL 33705, Telephone: (727) 894-2929

Lorca J. Divale, The Divale Law Group, P.A.,P.O. Box 22347 St. Petersburg, FL 33742, Telephone: (727) 321-5646

COUNSEL FOR ST. PETE MRI

TABLEOFCONTENTSPage

TABLE OF AUTHORITIES ....................................................................................iii

STATEMENT OF AMICUS CURIAE'S IDENTITY AND INTEREST.................. 1

. SUMMARY OF THE ARGUMENT ....................................................................... 7

I. STANDARD OF REVIEW.............................................................................7

II. GEICO'S PIP INSURANCE POLICY EXPRESSLY PROMISES TOPAY THE "REASONABLE" AMOUNT AND NEVER MENTIONS THENEW FEE SCHEDULE METHOD OF §627.736(5)(A)2-5................................ 7

III. THE 2012 AMENDMENTS CONFIRM THAT GEICO ISUNLAWFULLY RELYING ON THE FEE SCHEDULE METHOD............... 17

• IV. THE FEE SCHEDULE CASES ARE CORRECT AND GEICO ISBLATANTLY BREACHING THE EXPRESS PROVISIONS OF ITS OWNPIP INSURANCE POLICY ................................................................................ 19

CONCLUSION.......................................................................................................20

CERTIFICATE OF SERVICE ...............................................................................21

CERTIFICATE OF COMPLIANCE ......................................................................22

11

a TABLE OF AUTHORITIESPage

Cases

Advanced 3-D Diagnostics, a.a.o. Francois v. Liberty Mutual Ins. Co.,18 Fla.L. Weekly 522a (Orange County Ct. 2011)............................................. 2

a AFO Imaging Inc. v. Peak Prop.& Cas. Ins. Corp.,17 FLW Supp. 368a, ¶l 8 (Fla.13th Cir. Ct. Jan. 25, 2010)................................ 12

All Family Clinic ofDaytona Beach, Inc. v. State Farm Mutual Auto. Ins. Co.,685 F.Supp.2d 1297 (S.D. Fla.2010)................................................................. 12

Allstate Ins. Co v. Holy Cross Hosp., Inc.,961 So.2d 328 (Fla.2007)................................................................................... 20

American Independent Ins. Co. v. Gables Ins. Recovery, a.a.o. Lima,19 Fla.L. Weekly Supp. 14b (Fla.1lth Cir. Ct. App. Div. 2011)........................ 2

A merican Risk Assur. Co. v. Benrube,407 So.2d 993 (Fla.3d DCA 1981)....................................................................... 9

aAtkins v. Allstate Ins. Co.,

s 382 So.2d 1276 (Fla.3d DCA 1980)..................................................................... 9

Bayfront Medical Center, a.a.o. Compas v. Esurance Ins. Co.,17 Fla.L. Weekly Supp. 1228a (Pinellas County Ct. 2010)................................ 2

City ofHollywood v. Lombardi,770 So.2d 1196 (Fla.2000)................................................................................. 19

DCI MRI, Inc v. Geico Indem. Co.,79 So.3d 840 (Fla.4th DCA 2012).................................................................. 2, 15

Dorsal Rehab, Inc., a.a.o. Lopez v. State Farm Fire & Cas. Co.,17 Fla.L. Weekly Supp. 1259b (Broward County Ct. 2010)............................... 2

111

a Explorer Ins. Co. v. Physicians Group, LLC,16 Fla.L. Weekly Supp. 317a (Fla.13th Jud. Cir. Ct., 2009)............................ 2, 9

Gables Ins. Recovery, Inc., a.a.o. Gonzalez v. Mercury Ins. Co. ofFlorida,18 Fla.L. Weekly Supp. 1038a (Broward County Ct. 2011)............................... 2

Gary H. DiBlasio, MD., P.A., v. Progressive American Ins. Co.,13 Fla.L. Weekly Supp. 625a (Fla.15th Cir. Cty. Ct. 2006) ............................... 9

Geico Gen. Ins. Co. v. Virtual Imaging Services, Inc.,90 So.3d 321 (Fla.3rd DCA 2012)................................................................. 2, 15

Geico Indem. Co. v. Physicians Group, LLC,47 So.3d 354 (Fla.2d DCA 2010)...................................................................3, 10

Geico Indem. Co. v. Virtual Imaging Services, Inc.,79 So.3d 55 (Fla.3d DCA 2011).....................................................................2, 15

. Health Diagnostics ofMiami, LLC, a.a.o. Gelpi v. United Auto. Ins. Co.,18 Fla.L. Weekly 1055a (Broward County Ct. 2011)......................................... 2

High Definition Mobile MR1, Inc. v. State Farm Mut. Auto. Ins. Co.,18 Fla.Law Weekly Supp. 102b (Broward County Ct. 2010)............................. 2

Imaging Center of West Palm Beach, LLC, a.a.o. Guerrero v. GovernmentEmployees Ins. Co.,18 Fla.L. Weekly Supp. 907a (Palm Beach County Ct. 2011)............................ 2

Ivey v. A listate Ins. Co.,774 So.2d 679, 683-684 (Fla.2000)......................................................................6

Kingsway Amigo Ins. Co. v. Ocean Health, Inc.,63 So.3d 63 (Fla.4th DCA 2011)..............................................................2, 15, 17

Lake Worth Therapy Center, Inc., a.a.o. Spann v. Security National Ins. Co.,19 Fla.L. Weekly Supp. 373b (Broward County Ct. 2011)................................. 2

1V

a McGowan Spinal Rehab. Center, P.A. a/a/o Cannon v. Progressive Express Ins.Co., 15 Fla.L. Weekly Supp. 713a (Fla.4th Jud. Cir. Cnty. Ct. 2008)................. 9

Millennium Diagnostic Imaging Center, Inc. v. Security National Ins. Co.,882 So.2d 1027 (Fla.3d DCA 2004)................................................................... 12

, Millennium Radiology, LLC v. U.S. Security Ins. Co.,17 Fla.L. Weekly Supp. 1037a (Broward County Ct. 2010)................................ 2

Mitchell R. Pollack, MD., a/a/o Holland v. Progressive American Ins. Co.,13 Fla.L. Weekly Supp. 381 (Broward County, Cnty. Ct. 2006)........................ 9

a MRI Assoc. ofSt. Pete, Inc. v. State Farm Mut. Auto. Ins. Co.,755 F.Supp.2d 1205 (M.D. Fla.2010)................................................................ 15

MRI Associates ofSt. Pete, a.a.o. Volpe v. Safeco Ins.Co. ofIllinois,17 Fla.L. Weekly Supp. 686a (Hillsborough County Ct. 2010).................. 2, 7, 9

MRI Associates ofSt. Pete, Inc. v. Dairyland Ins. Co.,U.S. Dist. Ct., M.D. Fla. Case No. 8:11-ev-665-EAK-MAP ........................ 1, 15

MRI Associates ofSt. Pete, Inc. v. Direct General Ins. Co.,U.S. Dist. Ct., M.D. Fla.Case No. 8:12-cv-02408-MSS-AEP ............................ 1

MRI Associates ofSt. Pete, Inc. v. Esurance Ins. Co.,Hillsborough County Cir. Ct. Case No. 10-CA-003923 ...................................... 1

MRI Associates ofSt. Pete, Inc. v. First Acceptance Ins. Co.,

Hillsborough County Circuit Court Case No. 10-CA-003919............................. 1

MRI Associates ofSt. Pete, Inc. v. First Floridian Auto & Home Ins. Co.,Hillsborough County Cir. Ct. Case No. 10-CA-013131 ...................................... 1

MRI Associates ofSt. Pete, Inc. v. Geico Indem. Co.,a Hillsborough County Cir. Ct. Case No. 10-CA-003935 ...................................... 1

MRIAssociates ofSt. Pete, Inc. v. Mercury Ins. Co. ofFlorida,

Hillsborough County Cir. Ct. Case No. 08-CA-027873 ...................................... 1

• MRI Associates ofSt. Pete, Inc. v. Metropolitan Casualty Ins. Co.,Hillsborough County Cir. Ct. Case No. 10-CA-003921 ...................................... 1

MRI Associates ofSt. Pete, Inc. v. Nationwide Mut. Fire Ins. Co.,Hillsborough County Cir. Ct. Case No. 09-CA-025723 ...................................... 1

MRI Associates ofSt. Pete, Inc. v. USAA Cas. Ins. Co.,Hillsborough County Cir. Ct. Case No. 10-CA-016785 ...................................... 1

MRI Assocs. ofAm., LLC v. State Farm Fire & Cas. Co.,61 So.3d 462 (Fla.4th DCA 2011)...................................................................... 17

MRI Services I, LLC v. State Farm Fire & Cas. Co.,17 Fla.L. Weekly Supp. 1039a (Broward County Ct. 2010)............................... 2

National Nuclear Center, Inc., a.a.o. Lamothe v. State Farm Mut. Auto. Ins. Co.,17 Fla.L. Weekly Supp. 1124b (Broward County Ct. 2010)............................... 2

Nationwide Mut. Fire Ins. Co. v. AFO Imaging, Inc.,71 So.3d 134 (Fla.2d DCA 2011)...................................................................4, 15

Personal Injury Clinic a.a.o. Montero v. Mercury Ins. Co. ofFla.,17 Fla.L. Weekly Supp. 470a (Miami-Dade County Ct., 2010).......................... 2

Personal Injury Clinic a/a/o Simo v. United Auto. Ins. Co.,Slip. Op. Case No. 10-3946-SP-21 (Miami-Dade County, Cnty. Ct. Feb. 10,

2011)......................................................................................................................9

Physicians Group a/a/o Buckner v. Progressive Select Ins. Co.,16 Fla.L. Weekly Supp. 961a (Fla.12th Jud. Cir. Cty. Ct. 2009)........................ 9

Professional Consulting Services, Inc. v. Hartford Life & Accident Ins. Co.,849 So.2d 446 (Fla. 2d DCA 2003).................................................................... 14

Progressive Auto Pro Ins. Co. v. Doctor's Pain Management Assoc.,14 Fla.L. Weekly Supp. 1010a (Fla.9th Jud. Cir. Appellate Div. 2007)............. 9

V1

• Ronald J. Trapana, M.D., P.A., a.a.o. Saint Rose v. United Auto. Ins. Co.,18 Fla.L. Weekly 551a (Miami-Dade County Ct. March 16, 2011)................... 2

SOCC, PL v. State Farm Mut. Auto. Ins. Co.,95 So.3d 903 (Fla. 5th DCA 2012)..................................................................... 15

State Farm Florida Ins. Co. v. Nichols,21 So.3d 904 (Fla.5th DCA 2009)......................................................................20

Sturgis v. Fortune Ins. Co.,475 So.2d 1272 (Fla.2d DCA 1985)...................................................................20

e Universal Underwriters Ins. Co. v. Morrison,574 So.2d 1063 (Fla.1990).................................................................................20

USAA Casualty Ins. Co. v. DPI ofNorth Broward, LLC, a.a.o. Negrette,19 Fla.L. Weekly Supp. 925a (Fla.17th Jud. Cir. Ct. App. Div. 2012)............... 2

USAA Casualty Ins. Co. v. Millenium Radiology, LLC, a.a.o. Keiter,19 Fla.L. Weekly Supp. 928a (Fla.17th Jud. Cir. Ct. App. Div. 2012)............... 2

Wright v. Auto-Owners Ins. Co.,739 So.2d 180 (Fla.2d DCA 1999).....................................................................20

Statutes

§ 627.733, Fla. Stat. ..................................................................................................8

• § 627.736, Fla. Stat. .........................................................................................passim

§ 627.736(1)(a), Fla. Stat. ................................................................................. 13, 15

§ 627.736(5)(a), Fla. Stat. ...............................................................................2, 9, 14

§ 627.736(5)(a)1, Fla. Stat. .......................................................................4, 9, 13, 15

e § 627.736(5)(a)2, Fla. Stat. ..............................................................................passim

V11

§ 627.736(5)(a)3, Fla. Stat. ............................................................................... 12, 15

§ 627.736(5)(a)4, Fla. Stat. ..................................................................................... 15

§ 627.736(5)(a)5, Fla. Stat. ................................................................... 15, 16, 18, 19

§ 627.736(5)(b)1, Fla. Stat. .......................................................................................6

§ 627.736(5)(c)1, Fla. Stat. .......................................................................................6

Ch 76-168 Laws of Fla 6

• Ch. 76-266, Laws of Fla............................................................................................6

Ch. 77-457, Laws of Fla............................................................................................6

h 77-468 Laws of Fla

e Ch. 78-374, Laws of Fla............................................................................................6

Ch. 79-164, Laws of Fla............................................................................................6•

Ch. 79-40, Laws of Fla..............................................................................................6

Ch. 79-400, Laws of Fla............................................................................................6

Ch. 80-206, Laws of Fla............................................................................................6

Ch 81-259 Laws of Fla 6

Ch. 81-318, Laws of Fla............................................................................................6

Ch. 82-243, Laws of Fla............................................................................................6

Ch. 82-386, Laws of Fla............................................................................................6

Ch. 85-320, Laws of Fla............................................................................................6

V111

• Ch. 86-182, Laws of Fla............................................................................................6

Ch. 87-226, Laws of Fla............................................................................................6

Ch. 87-282, Laws of Fla............................................................................................6

Ch. 88-370, Laws of Fla............................................................................................6

Ch. 89-243, Laws of Fla............................................................................................6

Ch 89-282 Laws of Fla 6

Ch. 89-313, Laws of Fla............................................................................................6

Ch. 90-119, Laws of Fla............................................................................................6

Ch. 90-232, Laws of Fla............................................................................................6

Ch. 90-248, Laws of Fla............................................................................................6

Ch. 90-295, Laws of Fla............................................................................................6

Ch. 91-106, Laws of Fla............................................................................................6

Ch. 91-110, Laws of Fla............................................................................................6

. Ch. 91-128, Laws of Fla............................................................................................6

Ch. 91-224, Laws of Fla............................................................................................6

Ch. 92-318, Laws of Fla............................................................................................6

Ch. 93-120, Laws of Fla............................................................................................6

Ch. 93-289, Laws of Fla............................................................................................6

Ch. 94-123, Laws of Fla............................................................................................6

1X

• Ch. 95-202, Laws of Fla............................................................................................6

Ch. 95-211, Laws of Fla............................................................................................6

- w

Ch. 97-102, Laws of Fla............................................................................................6

Ch. 97-84, Laws of Fla..............................................................................................6

Ch 98-?23 Laws of Fla 6

Ch. 98-270, Laws of Fla............................................................................................6

Ch. 99-248, Laws of Fla............................................................................................6

h 9 -3 Laws of Fla

Ch. 99-381, Laws of Fla............................................................................................6

Ch. 99-8, Laws of Fla................................................................................................6

Ch. 2001-271, Laws of Fla........................................................................................6

Ch. 2001-63, Laws of Fla..........................................................................................6

Ch. 2002-387, Laws of Fla........................................................................................6

Ch 2003 2 Laws of Fla 6

Ch. 2003-261, Laws of Fla........................................................................................6

Ch 2003-411 Laws of Fla 6 10

Ch. 2004-5, Laws of Fla............................................................................................6

Ch. 2005-2, Laws of Fla............................................................................................6

Ch. 2005-3, Laws of Fla............................................................................................ 6

Ch. 2006-197, Laws of Fla........................................................................................ 6

Ch. 2006-290, Laws of Fla........................................................................................ 6

Ch. 2006-305, Laws of Fla........................................................................................ 6

Ch. 2007-150, Laws of Fla........................................................................................ 6

Ch. 2007-324, Laws of Fla.................................................................................. 6, 10

Ch. 2008-220, Laws of Fla.................................................................................. 6, 12

Ch. 2008-4, Laws of Fla............................................................................................ 6

Ch. 2009-21, Laws of Fla.......................................................................................... 6

Ch. 2012-197, Laws of Fla.................................................................................. 6, 18

Other Authorities

David Dietz and Darrell Preston, "Home Insurers' Secret Tactics Cheat FireVictims, Hike Profits," Bloomberg (August 3, 2007),www.bloomberg.com/apps/news?pid=newsarchive &sid=aIOpZROwhvNI....... 5

"Injuries in Auto Crashes," www.dmvflorida.org/2004-crash-data.shtml................ 4

Matthew Morriset, "Private Auto Insurance is the Biggest Source of IndustryProfits," Online Auto Insurance News (Dec. 7, 2011),http://news.onlineautoinsurance.com/ companies/private-car-insurance-profits-report-95713........................................................................................................... 5

Mollie Reilly and Max J. Rosenthal, "Insurance Claim Delays Deliver MassiveProfits to Industry by Shorting Customers,"Huffington Post (Dec. 13, 2011), available atwww.huff'mgtonpost.com/2011/12/13/insurance-claim-delays-industry-profits-allstate-mckinsey-company_n 1139102.html....................................................... 5

X1

e Stephen Gandel, "Geico's Profits Plunged in 2011,"CNN Money (Feb. 25, 2012), available at http://finance.fortune.cnn.com/2012/02/25/geico-berkshire-hathaway/...................................... 5

X11

a STATEMENT OF AMICUS CURIAE'S IDENTITY AND INTEREST

Amicus Curiae MRI Associates of St. Pete, Inc. ("St. Pete MRI") provides

• health care to Floridians injured in auto accidents. St. Pete MRI has filed numerous

class action lawsuits1 on behalf of thousands of Florida health care providers,

against Geico and other insurance companies that provide personal injury

protection ("PIP") coverage in Florida, concerning the same legal issue in this

appeal (i.e., whether an insurer can expressly promise in its insurance policy to pay

PIP claims based on the "reasonable" amount of a health care provider's charges,

but then pay a much lower amount based exclusively on a fee schedule method not

mentioned in the policy).

There are many published cases showing that since 2008, Geico and some

(but not all) other PIP insurers have routinely underpaid PIP claims using the new

1 St. Pete MRI's pending class action lawsuits include: MRI Assoc. ofSt. Pete, Inc.v. Dairyland Ins. Co., U.S. Dist. Ct., M.D. Fla. Case No. 8:11-ev-665-EAK-MAP;MRI Assoc. of St. Pete, Inc. v. Mercury Ins. Co. ofFlorida, Hillsborough CountyCir. Ct. Case No. 08-CA-027873 ; MRI Assoc. ofSt. Pete, Inc. v. Nationwide Mut.Fire Ins. Co., Hillsborough County Cir. Ct. Case No. 09-CA-025723; MRI Assoc.of St. Pete, Inc. v. First Acceptance Ins. Co., Hillsborough County Circuit CourtCase No. 10-CA-003919; MRI Assoc. of St. Pete, Inc. v. Metropolitan Cas. Ins.Co., Hillsborough County Cir. Ct. Case No. 10-CA-003921; MRI Assoc. of St.Pete, Inc. v. Esurance Ins. Co., Hillsborough County Cir. Ct. Case No. 10-CA-003923; MRI Assoc. of St. Pete, Inc. v. Geico Indem. Co., Hillsborough CountyCir. Ct. Case No. 10-CA-003935; MRI Assoc. of St. Pete, Inc. v. First FloridianAuto & Home Ins. Co., Hillsborough County Cir. Ct. Case No. 10-CA-013131;MRI Assoc. of St. Pete, Inc. v. USAA Cas. Ins. Co., Hillsborough County Cir. Ct.Case No. 10-CA-016785; and MRI Assoc. of St. Pete, Inc. v. Direct General Ins.Co., U.S. Dist. Ct., M.D. Fla.Case No. 8:12-cv-02408-MSS-AEP.

a fee schedule method of Section 627.736(5)(a)2-5, Florida Statutes (2008-2011),

without mentioning it in their policies.2 In these cases, the defendant PIP insurers

See, e.g., Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So.3d 63 (Fla.4thDCA 2011), rev. den., 86 So.3d 1113 (Fla. 2012); DCI MRI, Inc v. Geico Indem.Co., 79 So.3d 840 (Fla.4th DCA 2012); Geico Indem. Co. v. Virtual ImagingServices, Inc., 79 So.3d 55 (Fla.3d DCA 2011) (" Virtual I"); Geico Gen. Ins. Co.v. Virtual Imaging Services, Inc., 90 So.3d 321 (Fla.3rd DCA 2012) (" Virtual II");USAA Cas. Ins. Co. v. Millenium Radiology, LLC, a.a.o. Keiter, 19 Fla.L. WeeklySupp. 928a (Fla.17th Jud. Cir. Ct. App. Div. 2012); USAA Cas. Ins. Co. v. DPI ofNorth Broward, LLC, a.a.o. Negrette, 19 Fla.L. Weekly Supp. 925a (Fla.17th Jud.Cir. Ct. App. Div. 2012); American Ind. Ins. Co. v. Gables Ins. Recovery, a.a.o.Lima, 19 Fla.L. Weekly Supp. 14b (Fla.11th Cir. Ct. App. Div. 2011); Explorer

• Ins. Co. v. Physicians Group, LLC, 16 Fla.L. Weekly Supp. 317a (Fla.13th Jud.Cir. Ct., 2009); Personal Injury Clinic a.a.o. Montero v. Mercury Ins. Co. ofFla.,17 Fla.L. Weekly Supp. 470a (Miami-Dade County Ct., 2010); MRI Assoc. of St.Pete, a.a.o. Volpe v. Safeco Ins.Co. of Illinois, 17 Fla.L. Weekly Supp. 686a(Hillsborough County Ct. 2010); Natl. Nuclear Center, Inc., a.a.o. Lamothe v.State Farm Mut. Auto. Ins. Co., 17 Fla.L. Weekly Supp. 1124b (Broward CountyCt. 2010); Millennium Radiology, LLC v. U.S. Sec. Ins. Co., 17 Fla.L. WeeklySupp. 1037a (Broward County Ct. 2010); MRI Services I, LLC v. State Farm Fire& Cas. Co., 17 Fla.L. Weekly Supp. 1039a (Broward County Ct. 2010); Bayfront

5 Medical Center, a.a.o. Compas v. Esurance Ins. Co., 17 Fla.L. Weekly Supp.1228a (Pinellas County Ct. 2010); Dorsal Rehab, Inc., a.a.o. Lopez v. State FarmFire & Cas. Co., 17 Fla.L. Weekly Supp. 1259b (Broward County Ct. 2010); HighDef Mobile MRI, Inc. v. State Farm Mut. Auto. Ins. Co., 18 Fla.Law WeeklySupp. 102b (Broward County Ct. 2010); Advanced 3-D Diagnostics, a.a.o.Francois v. Liberty Mut. Ins. Co., 18 Fla.L. Weekly 522a (Orange County Ct.

• 2011); Ronald J. Trapana, MD., P.A., a.a.o. Saint Rose v. United Auto. Ins. Co.,18 Fla.L. Weekly 551a (Miami-Dade County Ct. March 16, 2011); HealthDiagnostics of Miami, LLC, a.a.o. Gelpi v. United Auto. Ins. Co., 18 Fla.L.Weekly 1055a (Broward County Ct. 2011); Gables Ins. Recovery, Inc., a.a.o.Gonzalez v. Mercury Ins. Co. ofFlorida, 18 Fla.L. Weekly Supp. 1038a (Broward

• County Ct. 2011); Imaging Center of West Palm Beach, LLC, a.a.o. Guerrero v.Government Employees Ins. Co., 18 Fla.L. Weekly Supp. 907a (Palm BeachCounty Ct. 2011); Lake Worth Therapy Center, Inc., a.a.o. Spann v. SecurityNational Ins. Co., 19 Fla.L. Weekly Supp. 373b (Broward County Ct. 2011).

typically stipulate that the plaintiff health care provider's charges are "reasonable"

and that the only remaining issue is whether the PIP insurer was authorized to rely

on the new fee schedule method, without mentioning that in its insurance policy.e

Likewise, in the case at bar, Geico did not dispute that the plaintiff health care

provider's $3,600 charge is reasonable, but instead of paying that reasonable charge

e as promised in the insured patient's PIP policy, Geico unilaterally relied on the new

fee schedule method (which is not mentioned in that policy) to pay merely

$1,989.57. In Geico Indem. Co. v. Physicians Group, LLC, 47 So.3d 354 (Fla.2d

DCA 2010), Geico relied on the fee schedule method to pay merely $1,122.86 for a

surgical procedure, where the physician's usual and customary charge was $13,500,

and Geico agreed to pay based on that $13,500 charge if the court ruled that the fee

schedule method could not be used. In other words, fraud and billing abuses by the

plaintiff health care providers are not involved in any of these cases.3

Nonetheless, the gross disparity between the reasonable amount charged and

the much lower amount that Geico paid demonstrates that the legal issue in this

case means millions (if not billions) of dollars to the insurance industry, Florida

health care providers, and Florida drivers. About 200,000 Floridians are injured

3 If insurers would simply pay the level of benefits expressly promised in their PIPpolicies and required by statutes, there would be little, if any, PIP litigation.Instead, they throw stones from glass houses, by arguing (without evidence) theyare being defrauded by doctors, when in reality, the insurance industry is probablyone of the most significant perpetrators of fraud and bad faith ever known.

each year in auto accidents. See, "Injuries in Auto Crashes," www.dmvflorida.org/

2004-crash-data.shtml. When the above-described underpayments are multiplied

by the number of people injured since the January 1, 2008 effective date of the new

fee schedule method and the number of different medical treatments involved, it is

apparent that PIP insurers are reaping windfall profits to the detriment Florida

health care providers, who in good faith render medical services to insured patients

with the reasonable expectation of receiving payment without unlawful reductions,

and to the determent of Florida drivers, who pay insurance premiums for the

maximum level of PIP benefits based on the reasonable amount method expressly

described in their insurance policies, instead of the "minimum amount" of PIP

benefits provided under the fee schedule method4 relied upon, sub silentio, by

Geico and other insurers, who promise one thing but deliver another.

Among all businesses in our country, the insurance industry stands out as

one which appears to have a "business model" of systematically breaching its own

contracts. Charging premiums for seemingly high benefits, while denying or

a underpaying legitimate claims, is highly profitable.° Not surprisingly, auto

4 Under the PIP statute, the "reasonable" amount is the maximum amount payable.See, §627.736(5)(a)1, Fla. Stat. In sharp contrast, in Nationwide Mut. Fire Ins. Co.v. AFO Imaging, Inc., 71 So.3d 134, 137 (Fla.2d DCA 2011), the court explainedthat the fee schedule method is "utilized in computing the minimum amount"payable by PIP insurance. (Emph. added).

5 See, e.g., David Dietz and Darrell Preston, "Home Insurers' Secret Tactics Cheat

insurance provides the largest source of profits to insurers.' In 2011, even after

dropping 48% from the previous year, Geico still reported huge profits of $587

million.7 Because of the huge dollars at stake, this case and others like it illustrate

that PIP insurers will continue denying and underpaying legitimate claims 8

While PIP insurers are reaping windfall profits by breaching their own

e insurance policies, health care providers are being whipsawed. With the

proliferation of unbridled regulation, managed care, governmental payers, and the

ever-growing number of uninsured patients, health care providers have seen their

operating expenses grow while their payment for services shrink. The situation is

worse when health care services are rendered to a PIP insured. When Florida's no-

Fire Victims, Hike Profits," Bloomberg (August 3, 2007), www.bloomberg.com/apps/news?pid=newsarchive &sid=aIOpZROwhvNI; Mollie Reilly and Max J.Rosenthal, "Insurance Claim Delays Deliver Massive Profits to Industry byShorting Customers," Huffington Post (Dec. 13, 2011),www.huffingtonpost.com/20ll/12/13/insurance-claim-delays-industry-profits-allstate-mckinsey-company_n_1139102.html.

6 See, Matthew Morriset, "Private Auto Insurance is the Biggest Source of IndustryProfits," Online Auto Insurance News (Dec. 7, 2011), http://news.onlineautoinsurance.com/companies/private-car-insurance-profits-report-95713.

7 Stephen Gandel, "Geico's Profits Plunged in 2011," CNNMoney (Feb. 25, 2012),http://finance. fortune.cnn.com/2012/02/25/geico-berkshire-hathaway/.

8 In FlOrida alone, a simple Westlaw search reveals over 450 published appellatee decisions since 2008 involving lawsuits concerning alleged breaches of insurance

policies, and a similar search of the Florida Law Weekly Supplement yields over135 more published cases for the same timeframe. Of course, only a smallpercentage of the overall number of lawsuits filed result in published decisions.

fault scheme was first adopted in 1971, its purpose was to provide swift and

virtually automatic payment for health care provided to an insured patient. See,

e.g., Ivey v. Allstate Ins. Co., 774 So.2d 679, 683-684 (Fla.2000). However, since

1971, the PIP statutes have been amended by 62 different session laws" and have

evolved into a complex quagmire of traps, hurdles, and loopholes that PIP insurers

a manipulate to their benefit and to the detriment of health care providers who

simply want to get paid for services rendered in good faith to insured patients.

When health care providers do not comply with some of the PIP statute's hyper-

technical requirements, their right to payment can be completely forfeited. See,

e.g., §627.736 (5)(b)1.d & (5)(c)l, Fla.Stat. Now, under the new fee schedule

e method, when health care providers do receive payment, the amount is a small

portion of that payable under the reasonable amount method.

PIP insureds are also being whipsawed. First, they are being charged

premiums calculated based on the maximum level of PIP benefits available under

the reasonable amount method promised in their PIP policies, but the PIP insurers

are actually paying out much lower benefits under the fee schedule method not

9 See, Chs. 76-168, 76-266, 77-457, 77-468, 78-374, 79-40, 79-164, 79-400, 80-206, 81-259, 81-318, 82-243, 82-386, 85-320, 86-182, 87-226, 87-282, 88-370, 89-243, 89-282, 89-313, 90-119, 90-232, 90-248, 90-295, 91-106, 91-110, 91-128, 91-224, 92-318, 93-120, 93-289, 94-123, 95-202, 95-211, 96-406, 97-84, 97-102, 98-223, 98-270, 99-3, 99-8, 99-248, 99-381, 2001-63, 2001-271, 2002-387, 2003-2,2003-261, 2003-411, 2004-5, 2005-2, 2005-3, 2006-197, 2006-290, 2006-305,2007-150, 2007-324, 2008-4, 2008-220, 2009-21, 2012-197, Laws of Florida.

a mentioned in the policies. Second, the PIP insurers' practice of expressly promising

to use the reasonable amount method in their policies, while they sub silentio apply

the fee schedule method, leaves PIP insureds potentially liable for the unpaid

balance of medical bills not covered by their PIP insurers. In the end, the PIP

insurers' much lower payments under the fee schedule method will ultimately

diminish the array and quality of health care providers who will agree to treat

patients with PIP coverage. See, Volpe, 17 Fla.L. Weekly Supp. 686a at ¶10.

SUMMARY OF THE ARGUMENT

PIP insurers must abide by the promises made in their own PIP policies, and

cannot unilaterally change the maximum level of PIP benefits for which policy

holders bargained when they initially purchased and/or renewed their PIP policies

and paid the premiums based on that maximum level of benefits.

e I. STANDARD OF REVIEW

St. Pete MRI agrees that the Third District's interpretation of the PIP statute

and Geico's insurance policy must be reviewed on a de novo basis.

II. GEICO'S PIP INSURANCE POLICY EXPRESSLY PROMISES TOPAY THE "REASONABLE" AMOUNT AND NEVER MENTIONSTHE NEW FEE SCHEDULE METHOD OF §627.736(5)(A)2-5

Geico is asking this Court to construe the unambiguous provisions of the

insured patient's PIP insurance policy and the 2008-2011 versions of the PIP

statute. However, Geico's brief fails to quote them. Accordingly, before this Court

s, 7

e.

attempts to answer the question certified below, it should compare and contrast the

applicable versions of the PIP statutes and Geico's own PIP policy. In pertinent

part, the pre-October 1, 2007 version of Section 627.736 (the "Former PIP

Statute") provided the following reasonable amount method for calculating PIP

benefits for medical expenses:

627.736 Required personal injury protection benefits...-

(1) REQUIRED BENEFITS.-Every insurance policy complyingwith the security requirements of s. 627.733 shall provide personal injuryprotection to the named insured, relatives residing in the same household,

a persons operating the insured motor vehicle, passengers in such motorvehicle, and other persons struck by such motor vehicle and suffering bodilyinjury while not an occupant of a self-propelled vehicle, subject to theprovisions of subsection (2) and paragraph (4)(d), to a limit of $10,000 forloss sustained by any such person as a result of bodily injury, sickness,disease, or death arising out of the ownership, maintenance, or use of amotor vehicle as follows:

(a) Medical benefits.-Eighty percent of all reasonable expenses formedically necessary medical, surgical, X-ray, dental, and rehabilitative

a services, including prosthetic devices, and medically necessary ambulance,hospital, and nursing services. Such benefits shall also include necessaryremedial treatment and services recognized and permitted under the laws ofthe state for an injured person who relies upon spiritual means throughprayer alone for healing, in accordance with his or her religious beliefs;however, this sentence does not affect the determination of what otherservices or procedures are medically necessary.

(5) CHARGES FOR TREATMENT OF INJURED PERSONS.-

(a) Any physician, hospital, clinic, or other person or institution lawfullyrendering treatment to an injured person for a bodily injury covered bypersonal injury protection insurance may charge the insurer and injuredparty only a reasonable amount pursuant to this section for the services and

, supplies rendered, and the insurer providing such coverage may pay for such

=8

charges directly to such person or institution lawfully rendering suchtreatment, if the insured receiving such treatment or his or her guardian hascountersigned the properly completed invoice, bill, or claim form approvedby the office upon which such charges are to be paid for as having actually

- been rendered, to the best knowledge of the insured or his or her guardian. Inno event, however, may such a charge be in excess of the amount the personor institution customarily charges for like services or supplies. Withrespect to a determination of whether a charge for a particular service,treatment, or otherwise is reasonable, consideration may be given to

e evidence of usual and customary charges and payments accepted by theprovider involved in the dispute, and reimbursement levels in thecommunity and various federal and state medical fee schedules applicable toautomobile and other insurance coverages,[*] and other information relevant

Medicare is welfare, and not the type of "federal and state medical fee schedulesapplicable to automobile and other insurance coverages" contemplated by formersubsection (5)(a) (presently, (5)(a)l) of the PIP statute. Thus, Florida courts haverepeatedly held as a matter of law that Medicare fee schedules cannot be reliedupon by PIP insurers to determine the "reasonable" amount payable under the PIPstatute. See, Atkins v. Allstate Ins. Co., 382 So.2d 1276 (Fla.3d DCA 1980);American Risk Assur. Co. v. Benrube, 407 So.2d 993 (Fla.3d DCA 1981); Gary H.DiBlasio, MD., P.A., v. Progressive American Ins. Co., 13 Fla.L. Weekly Supp.625a (Fla.15th Cir. Cty. Ct. 2006); Progressive Auto Pro Ins. Co. v. Doctor's PainManagement Assoc., 14 Fla.L. Weekly Supp. 1010a (Fla.9th Jud. Cir. AppellateDiv. 2007); McGowan Spinal Rehab. Center, P.A. a/a/o Cannon v. Progressive

a Express Ins. Co., 15 Fla.L. Weekly Supp. 713a (Fla.4th Jud. Cir. Cnty. Ct. 2008);Physicians Group a/a/o Buckner v. Progressive Select Ins. Co., 16 Fla.L. WeeklySupp. 961a (Fla.12th Jud. Cir. Cty. Ct. 2009); Mitchell R. Pollack, MD., a/a/oHolland v. Progressive American Ins. Co., 13 Fla.L. Weekly Supp. 381 (BrowardCounty, Cnty. Ct. 2006); Personal Injury Clinic a/a/o Simo v. United Auto. Ins.Co., Slip. Op. Case No. 10-3946-SP-21 (Miami-Dade County, Cnty. Ct. Feb. 10,2011). Thus, PIP insurers cannot rely on the fee schedule method under the guiseof the reasonable amount method. See, e.g., Explorer, 16 Fla.L. Weekly Supp.317a ("reasonable" amount may be proved through the elements described in§627.736(5)(a)l, and insurer's position that fee schedule method clarifiedreasonable amount to be charged by medical provider was erroneous); Montero, 17Fla.L. Weekly Supp. 470a (fee schedule in §627.736(5)(a)2 "leave[s] no room forinterpretation, and sets forth fixed payment schedules for services provided. It doesnot take into account the 'reasonableness' of the fee"); Volpe, 17 Fla.L. WeeklySupp. 686a at ¶l9 (reasonable amount test of former Section 627.736(5)(a) is not

to the reasonableness of the reimbursement for the service....

(Emph. added). In other words, before October 1, 2007, the Former PIP Statute

• "required" that PIP insurers "shall" pay 80% of the "reasonable amount."

Effective on October 1, 2007, the "Florida Motor Vehicle No-Fault Law"

(including the Former PIP Statute) was repealed by a "sunset" provision. See Ch.

2003-411, §19, Laws of Fla.(2003). Three months later, as of January 1, 2008, the

Legislature enacted a new PIP statute. See, Ch. 2007-324, §§ 8-21, Laws of

Fla.(2007); Physicians Group, 47 So.3d at 356 ("On January 1, 2008, the new

Florida Motor Vehicle No-Fault Law, including a new PIP statute, went into

effect") (emph. added). That new PIP statute identified two separate and distinct

methods to calculate PIP benefits and states:

627.736 Required personal injury protection benefits; exclusions;priority; claims.-

(1) REQUIRED BENEFITS.-Every insurance policy complyingwith the security requirements of s. 627.733 shall provide personalinjury protection to the named insured, relatives residing in the samehousehold, persons operating the insured motor vehicle, passengers insuch motor vehicle, and other persons struck by such motor vehicle andsuffering bodily injury while not an occupant of a self-propelled vehicle,subject to the provisions of subsection (2) and paragraph (4)(e), to a limitof $10,000 for loss sustained by any such person as a result of bodilyinjury, sickness, disease, or death arising out of the ownership,maintenance, or use of a motor vehicle as follows:

(a) Medical benefits.-Eighty percent of all reasonable expenses

replaced, substituted, clarified, or defined by the fee schedule method of the newversion of Section 627.736(5)(a)2-5).

10

for medically necessary medical, surgical, X-ray, dental, andrehabilitative services, including prosthetic devices, and medicallynecessary ambulance, hospital, and nursing services. However, themedical benefits shall provide reimbursement only for such services and

a care that are lawfully provided, supervised, ordered, or prescribed by aa physician licensed under chapter 458 or chapter 459, a dentist licensed

under chapter 466, or a chiropractic physician licensed under chapter460 or that are provided by any of the ... persons or entities [listed innew subparts 1 through 5]....

(5) CHARGES FOR TREATMENT OF INJURED PERSONS.-

_(a)1. Any physician, hospital, clinic, or other person or institutionlawfully rendering treatment to an injured person for a bodily injurycovered by personal injury protection insurance may charge the insurer

a and injured party only a reasonable amount pursuant to this section forthe services and supplies rendered, and the insurer providing suchcoverage may pay for such charges directly to such person or institutionlawfully rendering such treatment, if the insured receiving suchtreatment or his or her guardian has countersigned the properlycompleted invoice, bill, or claim form approved by the office uponwhich such charges are to be paid for as having actually been rendered,to the best knowledge of the insured or his or her guardian. In no event,however, may such a charge be in excess of the amount the person orinstitution customarily charges for like services or supplies. Withrespect to a determination of whether a charge for a particularservice, treatment, or otherwise is reasonable, consideration may begiven to evidence of usual and customary charges and paymentsaccepted by the provider involved in the dispute, and reimbursementlevels in the community and various federal and state medical feeschedules applicable to automobile and other insurance coverages,["]and other information relevant to the reasonableness of thereimbursement for the service, treatment, or supply.

2_. The insurer may limit reimbursement to 80 percent of thefollowing schedule of maximum charges:

a. For emergency transport and treatment by providers licensed

See, footnote 10 above.

11

under chapter 401, 200 percent of Medicare.b. For emergency services and care provided by a hospital licensed

under chapter 395, 75 percent of the hospital's usual and customarycharges.

c. For emergency services and care as defined by s. 395.002(9)provided in a facility licensed under chapter 395 rendered by a physicianor dentist, and related hospital inpatient services rendered by a physicianor dentist, the usual and customary charges in the community.

d. For hospital inpatient services, other than emergency services andcare, 200 percent of the Medicare Part A prospective payment applicableto the specific hospital providing the inpatient services.

e. For hospital outpatient services, other than emergency services andcare, 200 percent of the Medicare Part A Ambulatory PaymentClassification for the specific hospital providing the outpatient services.

. f. For all other medical services, supplies, and care, 200 percent ofthe applicable Medicare Part B fee schedule.[°] However, if suchservices, supplies, or care is not reimbursable under Medicare Part B, theinsurer nma2 limit reimbursement to 80 percent of the maximumreimbursable allowance under workers' compensation, as determinedunder s. 440.13 and rules adopted thereunder which are in effect at thetime such services, supplies, or care is provided. Services, supplies, orcare that is not reimbursable under Medicare or workers' compensationis not required to be reimbursed by the insurer.["]

Because subsections (5)(a)2.f and (5)(a)3 of the 2007 session law did not clearlyidentify "the applicable Medicare Part B fee schedule," the Legislature amendedthe new PIP statute in June 2008 to clarify that "the participating physiciansschedule of Medicare Part B" is the "applicable" fee schedule. All Family Clinic ofDaytona Beach, Inc. v. State Farm Mutual Auto. Ins. Co., 685 F.Supp.2d 1297,

w 1298 (S.D. Fla.2010); AFO Imaging Inc. v. Peak Prop.& Cas. Ins. Corp., 17 FLWSupp. 368a, ¶l8 (Fla.13th Cir. Ct. Jan. 25, 2010), affirmed, 71 So.3d 134 (Fla.2dDCA 2011); Ch. 2008-220, §22, Laws of Fla.(2008). The 2008 clarifyinglegislation was not a substantive change to the 2007 law and both versions must beconstrued to mean the same thing. Id. See also, Millennium Diagnostic ImagingCenter, Inc. v. Security National Ins. Co., 882 So.2d 1027 (Fla.3d DCA 2004).

Notably, under subsection (5)(a)2.f of the fee schedule method, "Services,supplies, or care that is not reimbursable under Medicare or workers' compensationis not required to be reimbursed by the insurer." So, if the PIP insurer relies on thefee schedule method for such services, the insured patient must bear 100% of

=12

3. For purposes of subparagraph [(5)(a)]2., the applicable feeschedule or payment limitation under Medicare is the fee schedule orpayment limitation in effect at the time the services, supplies, or care

, was rendered and for the area in which such services were rendered,e except that it may not be less than the applicable 2007 Medicare Part B

fee schedule for medical services, supplies, and care subject to MedicarePart B.

4. Subparagraph [(5)(a)]2. does not allow the insurer to apply anya limitation on the number of treatments or other utilization limits that

apply under Medicare or workers' compensation. An insurer thatapplies the allowable payment limitations of subparagraph [(5)(a)]2.must reimburse a provider who lawfully provided care or treatmentunder the scope of his or her license, regardless of whether such provider

a would be entitled to reimbursement under Medicare due to restrictions orlimitations on the types or discipline of health care providers who maybe reimbursed for particular procedures or procedure codes.

5. If an insurer limits payment as authorized by subparagraph[(5)(a)]2., the person providing such services, supplies, or care maynot bill or attempt to collect from the insured any amount in excessof such limits, except for amounts that are not covered by theinsured's personal injury protection coverage due to the coinsuranceamount or maximum policy limits.

(Emph. added). Thus, under the 2008-2011 PIP statute, the Legislature allowed PIP

insurers to calculate PIP benefits under either: (1) the pre-existing method of

paying 80% of the reasonable charges under Section 627.736(1)(a) and (5)(a)1 (the

"reasonable amount method"); or (2) a new altemative method of paying 80% of

the fee schedules listed in Section 627.736(5)(a)2-5 (the "fee schedule method").

In the subject PIP policy that Geico issued to the plaintiff health care

the charges. Under the reasonable amount method, the PIP insurer would ber responsible for 80% of the reasonable amount of those charges.

13

provider's insured patient," Geico unambiguously promised to pay for medical

expenses under the pre-existing reasonable amount method:

e The Company will pay, in accordance with the Florida MotorVehicle No-Fault Law, as amended, to or for the benefit of the injuredperson:

(a) 80% of medical expenses....

"Medical expenses" means reasonable expenses for necessary. medical, surgical, x-ray, dental, ambulance, hospital, professional

nursing and rehabilitative services for prosthetic devices and fornecessary remedial treatment and services recognized and permittedunder the laws of the state for an injured person.

3. CHANGESThe terms and provisions of this policy cannot be waived or

changed, except þ_y an endorsement issued to form a gad of thispolicy. We may revise this policy during its terms to provide morecoverage without an increase in premium. If we do so, your policywill automatically include the broader coverage when effective inyour state.

(A 7-8, 23-24, 32; bold and underline added; all other emph. omitted)." Nowhere

in the policy (including the "Limit of Liability" section) does it mention or suggest

that Geico would rely on any fee schedules, much less the fee schedule method of

Section 627.736(5)(a)2-5. Thus, after the new PIP statute took effect on January 1,

Before providing services, health care providers typically obtain an assignmentof insurance benefits from patients insured by PIP. Accordingly, in most PIP suits(including this case), the plaintiff health care provider stands in the shoes of the

an assignor insured patient. See, e.g., Professional Consulting Services, Inc. v.Hartford Life & Accident Ins. Co., 849 So.2d 446, 447 (Fla. 2d DCA 2003).

Citations herein to "A" refer to the Respondent's appendix.

14

e 2008, the insured patient's PIP policy continued to describe the same pre-existing

higher level of PIP benefits required by the Former PIP Statute, which was carried

forward in subsections (1)(a) and (5)(a)1 of the 2008-2011 PIP statute.

Although the new PIP statute also authorizes PIP insurers to pay lower

benefits based on the new fee schedule method, that new method is an alternative

which is separate and distinct from the reasonable amount method.16 First,

subsection (5)(a)2 states the insurer "may" (not "shall") "limit reimbursement" by

using the various Medicare and workers' compensation fee schedules enumerated

therein. Next, (5)(a)3 states that Medicare fee schedules only apply "[fjor purposes

of subparagraph [(5)(a)]2...." Next, (5)(a)4 provides that the fee schedule method

a does not allow PIP insurers to rely on limitations that otherwise apply under the

Medicare and workers' compensation systems. See, Nationwide, 71 So.3d at 137-

138; SOCC, PL v. State Farm Mut. Auto. Ins. Co., 95 So.3d 903, 909-910 (Fla. 5th

DCA 2012). Lastly, (5)(a)5 provides that "If" the insurer limits payment as

authorized by the fee schedule method, then the health care provider is not allowed

na '® Geico's reliance on MRI Assoc. of St. Pete, Inc. v. State Farm Mut. Auto. Ins.Co., 755 F.Supp.2d 1205 (M.D. Fla.2010) is misplaced. First, that federal trialcourt decision was issued before, and directly conflicts with, Kingsway, DCI MRI,Virtual I, and Virtual II. Second, the federal trial judge did not address any of the

e prior published Florida cases cited in fn. 2 herein. Third, after Kingsway wasa entered, the same federal trial judge recently certified a class action in an identical

case. See, MRI Associates of St. Pete, Inc. v. Dairyland Ins. Co., U.S. Dist. Ct.,M.D. Fla.Case No. 8:11-cv-665-EAK-MAP, Online Docket, Doc. #32.(www.fimd.uscourts.gov).

15

to balance-bill the insured patient for any portion of the bill not paid by the PIP

insurer "except for amounts that are not covered by the insured's [PIP] coverage

due to the coinsurance amount or maximum policy limits."

Subsection (5)(a)5 is the most important for illustrating the separate and

distinct nature of the reasonable amount method and the fee schedule method.

e First, (5)(a)5 states that it only applies "If" the insurer uses the fee schedules in

(5)(a)2, and thereby recognizes that the insurer is not required to use those feee

schedules. Second, it prohibits the health care provider from balance-billing the

patient when the fee schedule method is used, "except" for charges that are not

covered by PIP due to coinsurance or exhaustion of PIP benefits. Third, by

implication, it maintains the health care provider's right to balance-bill the insured

patient whenever the PIP insurer uses the reasonable amount method, or whenever

there is no PIP coverage due to coinsurance, or exhaustion of PIP coverage. If, as

Geico and its amici suggest, the reasonable amount method and the fee schedule

method are one and the same method, why would the Legislature allow the health

care provider to balance-bill insured patients when the PIP insurer does not rely on

the fee schedules listed in (5)(a)2, or when there is no PIP coverage due to

coinsurance or exhaustion? Indeed, to adopt Geico's argument, this Court must

adopt a judicial construction that completely ignores or rewrites (5)(a)5.

The foregoing ramifications of (5)(a)5 are also important because

16

subsections (5)(d) and (10)(b)3 of the PIP statute require the health care provider's

initial claim form and pre-suit demand letter specify the "exact amount" owed.

MRI Assocs. of Am., LLC v. State Farm Fire & Cas. Co., 61 So.3d 462 (Fla.4th

DCA 2011). "Such precision is not possible" where the policy does not specify

which payment calculation method will be used. Kingsway, 63 So.3d at 68. It is

= doubtful that the Legislature intended to create a trap that would prevent doctors

from properly filling out their claim forms and demand letters whenever a PIP

insurance policy does not expressly adopt the fee schedule method.

As in the cases cited in fn. 2, Geico's PIP policy here describes only the

reasonable amount method, and not the fee schedule method. Geico's policy also

e expressly prohibits unilateral unwritten changes to the policy. Consequently, the

health care provider's lawful authority to balance-bill the patient, the patient's legal

obligation to pay any balance-billed charge, and the health care provider's ability to

properly complete its initial claim form and demand letter, are established by

Geico's election to describe only the reasonable amount method in its PIP policy.

III. THE 2012 AMENDMENTS CONFIRM THAT GEICO ISUNLAWFULLY RELYING ON THE FEE SCHEDULE METHOD

A PIP insurer's inability to rely on the fee schedule method when its

insurance policy only describes the reasonable amount method has been hotly

litigated since 2008. See, e.g., Cases cited in fn. 2 herein.

The Third District issued its decision and certified question below on April•

17

25, 2012. Several days later, on May 4, 2012, the Legislature promptly answered

the Third District's question by codifying the holdings in the cases cited in fn. 2

herein. Specifically, the Legislature inserted a new subsection (5)(a)5 into the

current 2012 version of Section 627.736, which reads as follows:

5. Effective July 1, 2012, an insurer may limit payment asauthorized by this paragraph only if the insurance policy includes anotice at the time of issuance or renewal that the insurer may limitpayment pursuant to the schedule of charges specified in this paragraph.

Ch. 2012-197, § 10, Laws of Fla. (2012).

Not only does the 2012 version of subsection (5)(a)5 codify the published

cases cited in fn. 2 herein, but it also imposes additional requirements not

expressed in those cases. Although those published cases uniformly required PIP

insurers to clearly adopt the fee schedule method in their PIP policies before

relying on that method, such an adoption could have been buried anywhere in the

policy or done at any time with an amendatory endorsement. However, as of July

1, 2012, the 2012 version of (5)(a)5 now imposes the additional requirements that

the fee schedule method can "only" be adopted by a "notice" in the policy at the

time of "issuance or renewal." So, the fee schedule method can no longer be

adopted by a provision buried in the fine print of a lengthy policy, or by an

amendatory endorsement during the policy term period after the premium is paid.

The Legislature is presumed to know about the prior litigation and published

judicial constructions of the PIP statute when amending it, and is also presumed to

18

= have adopted those constructions when amending the PIP statute, unless a contrary

intention is expressed when amending it. See, e.g., City ofHollywood v. Lombardi,

770 So.2d 1196, 1202 (Fla.2000). Nothing in the 2012 adoption of the new (5)(a)5

expresses any intent to overturn Kingsway and the other cases cited in fn. 2.

To the contrary, we must presume that when the Legislature adopted the new

. (5)(a)5, it was aware that many cases had decided the fee schedule method had to

be expressly adopted in the PIP policy. When inserting the new (5)(a)5 and

codifying those prior published decisions, and also placing additional requirements

on how and when the fee schedule method could be adopted, it is obvious that the

Legislature did so to end to the debate. Indeed, what other purpose could the

Legislature have intended by inserting the new (5)(a)5 but to clarify and confirm

that PIP insurers must abide by the promises made in their own PIP policies, and

cannot unilaterally and silently change the maximum level of PIP benefits for

which policy holders bargained when they initially purchased and/or renewed their

PIP policies and paid the premiums based on that maximum level of benefits?

IV. THE FEE SCHEDULE CASES ARE CORRECT AND GEICO ISBLATANTLY BREACHING THE EXPRESS PROVISIONS OF ITSOWN PIP INSURANCE POLICY

The sound rationale expressed in the many published cases cited in fn. 2

herein speaks for itself, as does the plain language of Geico's own PIP policy-

which is conspicuously absent from Geico's brief. Also, as explained in many of

19

those cases, nothing prevents PIP insurers from agreeing in their policies to

provide a higher level of PIP benefits than the minimum amount afforded by the

statutory fee schedule method. See also, State Farm Florida Ins. Co. v. Nichols, 21

So.3d 904 (Fla.5th DCA 2009); Universal Underwriters Ins. Co. v. Morrison, 574

So.2d 1063 (Fla.1990); Sturgis v. Fortune Ins. Co., 475 So.2d 1272 (Fla.2d DCA

= 1985); Wright v. Auto-Owners Ins. Co., 739 So.2d 180 (Fla.2d DCA 1999). This

Court should not decide this appeal without reading all the cases cited in fn. 2.

Geico's reliance upon Allstate Ins. Co v. Holy Cross Hosp., Inc., 961 So.2d

328 (Fla.2007) is misplaced. In that case, this Court's analysis "assumes the

existence of enforceable contracts by which [the plaintiff hospital] agreed to accept

PPO rates from [the PIP insurer] for any of its insureds that received treatment

covered by their PIP policies." Id. at 331, n. 2. There is no such contract in this

case. To the contrary, in this case, the only contract is the one that Geico has failed

to quote in its brief, which expressly promises to pay the "reasonable" amount and

says nothing about the fee schedule method.

Simply stated, Geico is crying crocodile tears. Geico manifests unmitigated

temerity by claiming to be the victim, when in reality it is the wrongdoer.

CONCLUSION

WHEREFORE, St. Pete MRI requests this Honorable Court to answer the

certified question in the negative, and affirm the Third District's decision below.

20

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy hereof was served by

Email on the following persons, on thisÜ day of NOS , 20 $ :

• Counsel for Petitioner, Geico General Insurance Company: Frank A.Zacherl, Esquire, Email - fzacherl@shutts.com; Suzanne Labrit, Esquire, Email- slabrit@shutts.com; and Jerel C. Dawsen, Esquire, Email -

e jdawson@shutts.com;

• Counsel for Respondent, Virtual Imaging Services, Inc.: John Beranek,Esquire, Email - jberanek@ausley.com; Harley N. Kane, Esquire, Email -harley@kanelawyers.com; and Joseph P. Littman, Esquire, Email -

a joseph@kanelawyers.com;

• Counsel for Florida Personal Injury Federation of Florida and NationalAssociation of Mutual Insurance Companies: Mary L. Aldrich, Esquire,Email - marcy.aldrich@akerman.com; Nancy A. Copperthwaite, Esquire, Email

• - nancy.copperthwaite@akerman.com; and Nancy M. Wallace, Esquire, Email -nancy.wallace@akerman.com;

• Counsel for American Insurance Association and Property CasualtyInsurers Association of America: Raoul G. Cantero, Esquire, Email -raoul.cantero@whitecase.com; T. Neal McAliley, Esquire, Email -nmcaliley@whitecase.com; and Jesse L. Green, Esquire, Email -jgreen@whitecase.com;

• Counsel for Florida Justice Reform Institute: Cynthia S. Tunnicliff, Equire,Email - cynthia@penningtonlaw.com; and Gerald D. Nelson Bryant, IV,Esquire, Email - jbryant@penningtonlaw.com;

• Counsel for the Travelers Companies, Inc.: Mark D. Tinker, Esquire, Email -mtinker@bankerlopez.com;

• Counsel for Floridians for Fair Insurance, Inc.: Lawrence M. Kopelman,Esquire, Email - larry@kopelblank.com; and

21

a • Counsel for Gables Insurance Recovery, Inc.: Robert N. Pelier, Esquire,Email - Rpelier@Pelierlaw.com, and Bart Billbrough, Esquire, Primary Email -bbillbrough@attyfla.com; Secondary Email - service@attyfla.com.

CERTIFICATE OF COMPLIANCE

I HEREBY CERTIFY that the text herein is printed in Times New Roman14-point font, and that this brief complies with the font requirements of FloridaRule of Appellate Procedure 9.210.

• Respectfully Submitted,

de la PARTE & GILBERT, P.A.David M. Caldevilla, FBN 654248Primary Email: dcaldevilla@dgfirm.comSecondary Email: serviceclerk@dgfirm.comMichael R. Bray, FBN 58263Primary Email: mbray@dgfirm.comSecondary Email: serviceclerk@dgfirm.com

e Post Office Box 2350Tampa, FL 33601-2350Telephone: (813) 229-2775

and

CRAIG E. ROTHBURD, P.A.Craig E. Rothburd, FBN 49182Email: crothburd@e-rlaw.com800 W. De Leon Street

a Tampa, FL 33606-2722Telephone: (813) 251-8800

and

22

THE JEEVES LAW GROUP, P.A.Scott R. Jeeves, FBN 0905630Primary Email: sjeeves@jeeveslawgroup.comSecondary Email: amyers@jeeveslawgroup.com954 First Avenue NorthSt. Petersburg, FL 33705Telephone: (727) 894-2929

and

THE DIVALE LAW GROUP, P.A.Lorca J. Divale, FBN 0173622Email: loreadig@gmail.comP.O. Box 22347St. Petersburg, FL 33742Telephone: (727) 321-5646

Counsel for Amicus Curiae,MRI Associates of St. Pete, Inc.,d/b/a St. Pete MRI

23

delaParte&Gilbert,PAVivian Arenas-Battles ATTORNEYS AT I..AW Patrick J. McNamara

Michael R. Bray Kristin Y. Melton

David M. Caldevilla Kristin K. MorrisEdward P dela Parte, Jr. Eric D. NowakRichard A. Gilbert Nicolas Q. Porter

Daniel J. McBreenLouis A. de la Parte, Jr.

November 8, 2012 founder119292008)

By Federal Express

Mr. Thomas D. Hall, ClerkFlorida Supreme Court500 South Duval StreetTallahassee, Florida 32399-1927

Re: Geico General Insurance Company v. Virtual Imaging Services, Inc., as assigneeofMaria Tirado, Fla. S. Ct. Case No. SC12-905

Dear Mr. Hall:

This law firm serves as appellate counsel to the Amicus Curiae, MRI Associates of St.Pete, Inc. ("St. Pete MRI"). Enclosed for filing are one original and seven copies of "St. PeteMRI's Amicus Curiae Brief in Support of Respondent." Also, in accordance with AdministrativeOrder No. AOSC04-84, an electronic copy (in Microsoft Word format) of this brief has beenemailed to the Court.

Thank you for your attention to this matter. Please call me if you have any questions orcomments.

Sincerely,

Enclosurescc: All counsel of record (w/ encl., by email)

de la Parte & Gilbert, P.A.

David M. Calde illato

(°°*1 °1} 101 East Kennedy Blvd., Suite 2000 Tampa, Florida 33602Mailing Address: Post Office Box 2350 Tampa, Florida 33601-2350

T: (813) 229-2775 E (813) 229-2712 www.dgfirm.com