Filing # 63173756 E-Filed 10/23/2017 12:08:33 PM
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`iN THE COUNTY COURT IN AND
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`FOR BROWARD COUNTY, FLORIDA
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`CASE NO. COSO 17-002584 {61)
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`MILLENIA CHIROPRACTTC, LLC
`AKA/O JULITA CHERRY,
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`Plaintiff,
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`STATE FARM MUTUAL AUTOMOBILE
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`INSURANCE COMPANY,
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`Defendant.
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`/
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`DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT
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`REGARDING UNBUNDLING
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`COMES NOW, Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE
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`COMPANY (hereinafter “STATE FARM”), by and through its undersigned counsel, and
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`pursuant to the Florida Rule of Civil Procedure 1.510(0), hereby files its Motion for Fina}
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`Summary Judgment against MILLENIA CHIROPRACTIC, LLC (hereinafter “‘Plaintift”), as the
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`assignee of JULITA CHERRY (hereinafter “Claimant”), and in support thereof states as foilows:
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`BACKGROUND
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`1. On or about February 20, 2017, Plaintiff filed its Complaint, alleging an action for
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`Breach of Contract and seeking the recovery of personal injury protection benefits.
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`2. Prior to filing its Complaint, on or about August 5, 20 I 6, Plaintiff sent Defendant a
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`Demand Letter, wherein Plaintiff alleged the amount charged by Plaintiff as $8,270.00,
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`the amount due at 80% as $6,616.00, and the amount paid by Defendant as $6,415.20.
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`3. Defendant concurs that the amount charged by Plaintiff was $8,270.00; however,
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`Defendant avers $6,604.00 was paid to Plaintiff. Please see Explanations ofReview
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`attached to Pfaintt'fl’s Complaint and attached hereto as Exhibit “A. ”
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`Page 1 of 5
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`*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 10/23/2017 12:08:32 PM.****
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`
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`4. Pursuant to the terms and conditions of the subject insurance policy, Defendant is
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`responsible for “80% of all reasonable [medical expenses].” Please see subject insurance
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`poiiey attached hereto as Exhibit “B. ”
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`5. All bills were properly paid at 80% of their billed amount, with the exception of CPT
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`Code A4556, which was billed on the initial date of service, March 20, 2013.
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`6. The sole charge that was not paidat 80% is CPT Code A4556, which was denied
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`payment. This CPT Code for $15.00 electrodes was not approved based on Reason Code
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`SF01 l, which states that the CPT/HCPCS code is included in another procedure reported
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`on the hill.
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`7. Defendant avers that payment was properly denied for CPT Code A4556 on March 20,
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`2013, that all other charges from Plaintiff were reimbursed at 80% of their billed amount,
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`and there are no genuine issues of material fact.
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`ARGUMENT
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`1. Legal Standard for Summam Judgment
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`8. The entry of summary judgment under Florida Rule of Civil Procedure 1.510 is proper if
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`there are no genuine issues of material fact in dispute and the moving party demonstrates
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`its entitlement to judgment as a matter of law. The non-moving party, in meeting its
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`burden, cannot merely assert that a genuine issue of material fact exists, but must come
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`forward with competent evidence to support that position. Fiesel V. Wynns, 661 So.2d
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`761 (Fla. 1996); Carboneil v. BelZSouth Telecommunications} Inc, 675 80.2d705 (Fla. 3d
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`DCA 1996).
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`9. The moving party must conclusively ShOW the absence of any genuine issue of material
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`fact and the court must draw every possible inference in favor of the party against whom
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`summary judgment is sought. Hodge V. Xtra Super Food Centers, 677 So.2d 405 (Fla. 3d
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`DCA 1996).
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`Page 2 of 5
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`10. When the moving party shows that no material fact on any issue is disputed, the burden
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`shifts to the non—moving party to demonstrate that a material fact is in dispute. People
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`Gas System v. Acme Gas Corp, 689 So.2d 292 (Fla. 3d DCA 1997). If the party opposing
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`summary judgment cannot show the existence of a genuine issue of material fact, then the
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`moving party should be entitled to judgment as a matter of law. Martin County v,
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`Edenfleio’, 609 So.2d 27 (Fla. 1992).
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`II. The State Farm Policy
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`11.
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`The terms of the policy at issue in this action are unambiguous and must be applied as
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`written. The Florida No-Fault ("PIP") provisions include the following provisions:
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`What We Pay
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`We will pay in accordance with the N0~Fault Act for bodily injury to an
`insured, caused by an accident resulting from the ownership, maintenance
`or use of a motor vehicle:
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`(Ex. B, Policy Booklet, Form 8107, at 12).
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`12.
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`While the policy booklet contains additional provisions regarding PIP coverage,
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`these provisions are substantially revised by Amendatory Endorsem*nt 6910.3,
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`which is also part of the policy. As set forth in the Amendatory Endorsem*nt,
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`State Farm’s payment obligations are further defined as follows:
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`b. Item 1. Of What We Pay is changed to read:
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`1. Medical Expenses. 80% of all reasonable expenses incurred for:
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`a. medicaib: necessary medical, surgical, X—ray, dental, ambulance, hospital,
`professional nursing and rehabilitative services, eyeglasses, hearing aids and
`prosthetic devices; and
`=5< * >§<
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`. To determine Whether a charge is reasonable we may consider usual and
`.
`.
`.
`customary charges and payments accepted by the provider, reimbursem*nt levels
`in the community and various federal and state medical fee schedules applicable
`to automobile and other insurance coverages, and other information relevant to
`the reasonableness of the reimbursem*nt for the service, treatment or supply. We
`will not pay any charge that the No-Fault Act does not require us to pay, or the
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`Page 3 of5
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`
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`amount of any charge that exceeds the amount the No-Fault Act allows to be
`charged.
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`(Ex. 13, Amendatory Endorsem*nt 69103 at 3-4).
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`13. The policy defines the "No~Fault Act" as "the Florida Motor Vehicle No-Fault Law and
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`any amendments.”
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`14. In compliance with the terms of said policy, Defendant paid 80% of all reasonable
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`expenses submitted by Plaintiff, with the exception of CPT Code A4556, which was
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`properly denied reimbursem*nt as being included in another procedure reported on the
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`bill.
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`III. Unbundling
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`IS. Pursuant to Florida Statute §627.736 (S)(B)1(E), an insurer is not required to pay a claim
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`or charges “[t}or any treatment or service that is upcoded, or that is unbundled when such
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`treatment or services should be bundled...”
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`16. Defendant avers that the sole CPT Code that was not paid at 80% of its charge, A4556,
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`was improperly unbundled from CPT Code (30283 on March 20, 2013. Please see
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`Aflidavi: ofJessica Schmor attached hereto as Exhibit “C. ”
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`17. Based on the expert opinion of Jessica Schmor, there is no genuine issue of material fact
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`that CPT Code A4556 was improperly unbundled from CPT Code G0283, and that State
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`Farm properly denied payment for this CPT Code.
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`18. As all other bills were reimbursed at 80% of their charged amount, there remains no
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`claim for personal injury protection benefits available to Plaintiff.
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`WHEREFORE, the Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE
`
`COMPANY, respectfully request that the Court grant Defendant’s Motion for Final Summary
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`Judgment, finding that CP'l‘ Code A4556 was improperly unbundled from CPT Code (30283, and
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`for such other and further relief it deems just and proper.
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`Page 4 of 5
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`CERTIFICATE OF SERVICE
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`I HEREBY CERTIFY that a true and correct copy of the foregoing was electronically
`
`
`delivered on October 23 2017, Evan Brown, Esq, Reifkind; Thompson & Rudzinski, PL, 12545
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`Orange Drive, Suite 503, Davie, FL 33330; gipoervicegzflrtrlawcom.
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`VERNIS & BOWLING 0F BROWARD, PA.
`Attorney/0r Defendant
`5821 Hollywood Boulevard,
`Hollywood, Florida 33021
`Tel: (954) 927-5330; Fax: (954) 927—5320
`Designated E-mail: pleading52@florida—law.com
`
`BY:
`
`/s/ CraigH. Shandler
`CRAIG H. SHANDLER, ESQ.
`Florida Bar #: 104810
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`Page 5 of S
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`DEFINED WORDS
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`repliecement car tfyou or your spouse:
`1.
`tell us about it within 30 days after its
`delivery to you or your spouse; and
`2‘ pay us any added amount due.
`Additiooat Car - means an added cariplurchased
`by or leased toawe oryour spouse.
`is poltcy
`ygill only provi e coverage for theadditional car
`i
`:
`1.
`it is a rivatepassenger car and we insure
`all ot er private passenger cars; or
`
`2‘
`
`it is other than a private passenger car
`and we insure all cars
`
`owned by you or your spouse on the date of its
`delivery to you or your spouse.
`
`This policy provides coverage for the additional
`car only unttl the earlier of:
`
`l.
`
`12:01 AM. on the 3lst day after the de-
`livery of the car to you oryour spouse; or
`
`2.
`
`the effective date and time of a policy
`issued by us or anycther company that
`describes the car on its declarations page.
`You or your spouse may apglfi for a polic that
`W111 provide coverage beyon t ‘6: 30th day or the
`additional car. Such policy Will be issued only
`if both you and the vehicle are eligible for cover—
`age at the time of application.
`
`If a newly chuired car is not otherwise afforded
`comprehenswe or collision coverage by this or any
`other policy. this policy wtll provide the comprehen-
`sive or collision coverage not otherwise provndcd for
`the newly acquired car. If such coverage is provided
`by this paragraph, it will apply only until 12:01 AM.
`Standard Time at the address shown on the declara-
`tions page on the sixth day after the delivery of the
`car to you or your spouse. Any comprehensive or
`collision coverage provided by this paragraph IS sub-
`ject to a dcducti
`le of $500.
`
`NomOwned Car - means acar not owned, registered
`or leased by:
`
`1. you, your spouse;
`
`2.
`
`any reiativehnless the car meets the require-
`ments described below;
`
`3. any otherperson residing in the same‘housen
`be d as you, your spouse or any ”have: or
`
`4.
`
`an employer ofyou, your spouse or any rela-
`five.
`
`A car owned. registered or leased b arelative is
`considered a aon-owued car that t e time‘ofnhe
`accrdent or loss, the car has been insured for liability
`
`3
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`8107
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`TM
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`covcra e within the last 30 do 3 and is driven by an
`rosette who does not own or case the cor.
`
`Narrowed cor does not include a:
`
`I.
`
`rented car while it is used in connection with
`the tnsured’s employment or busmess; or
`
`2. car which has been operated or rented by or
`in the possession of an insured during any
`part of each ofthe last 21 or more consecutive
`days. If the insured is an insured under one
`or more other car policies issued by us. the 2]
`day limit is increased by an additional 21 days
`for each such additional policy.
`
`A non-owned car must be a car in the lawful posses-
`Ston of the person operatmg tt.
`
`Occupying — means in, on, entering or alighting from.
`
`Person - means a human being.
`
`Private Passenger Car ... means a car:
`
`1, with four wheels;
`
`2. of the private passenger or station wagon
`type; and
`
`3. designed solely to carry persons and their
`luggage.
`
`Relative w as used in Sections 1. III. IV and V means
`:1 person related to you or your spouse by blood,
`marriage or adoption (including a ward or foster
`child) who resides frimarily With you. It includes
`year immanied an
`unemancipated child away at
`so 00 .
`As used in Section 11, relative means a relative ofany
`degree by blood or by marriage who usually makes
`his home in’the same family unit, whether or not
`temporarily living elsewhere.
`
`Sgouse .. means your husband or wife who resides
`primarily with you.
`Temporary Substitute Car - means acar not owned
`bar you or your spouse, if it replaces your car for a
`s on time. Its use has to be With the consent of the
`owner. Your car has to be out of use due to its
`breakdown, repair, servicingl damage or loss. A rem»
`porary substitute car is not consudered a non-owned
`car.
`
`Utility Vehicle — means a motor vehicle with:
`
`l. a pickup. panel or van body; and
`
`t
`
`2.
`
`ftGross Vehicle Weight of l0,000 pounds or
`css.
`
`You or Your — means the named insured or named
`insureds shown on the declarations page.
`Your Car — means the car or the vehicle described on
`the declarations page.
`
`DECLARATIONS CONTINUED
`
`We, the State Farm Mutual Automobile Insurance
`Company.» agree to insure you according to the terms
`of this policy based:
`1. on your payment of premium for the cover-
`ages you chose; and
`
`2.
`
`in reliance on your statements in these decla-
`tattoos.
`
`You agree, by acceptance of this policy that:
`l.
`the statements in these declarations are your
`statements and are true; and
`
`2. we Ensure you on the basis your statements
`are true; and
`
`3.
`
`this policy contains all of the agreements
`between you and us or any of our agents.
`
`Unless otherwise stated in the exceptions space on
`the declarations page, your statements are:
`
`1. Ownership. You are the sole owner of your
`car.
`
`2.
`
`Insurance and License Histo . Neither you
`nor any member ofyour house old wrthtn the
`past 3 years has had:
`
`a. vehicle insurance canceled by an insurer;
`or
`
`b.
`
`a license to drive or vehicle registration
`suspended, revoked or refused.
`
`3. Use. Your car is used for pleasure and busi-
`ness.
`
`8107
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`
`
`
`[w
`
`WHEN AND WHERE COVERAGE APPLiES
`
`When Coverage Applies
`
`The coverages you chose apply to accidents and
`losses that take place during t e policy period.
`
`The
`licy period is shown under “Policy Period" on
`the eclarattons 83%: and is for successive periods of
`six months eac
`or which you pay the renewal
`premium. Payments must be made on or before the
`end of the current
`lic
`riod. The olicy
`riod
`be ins and ends at 2:0?!ECM. Standarg Timeprft the
`ad ress shown on the declarations page.
`
`Where Coverage applies
`
`1. The liability, medical ayments, uninsured motor
`vehicle and physiea damage coverages you
`chose apply:
`
`a.
`
`in the United States of America, its territories
`and possessions or Canada; or
`
`The liability. medical payments and physical
`dame e covera es aiso apply in Mexico within
`50 mi es of the
`nited States border. A physical
`damage coverage loss to Mexico is determined
`on‘the basns of cost at the nearest United States
`p*rnt.
`
`2. The rte-fault coverage you chose applies:
`a.
`in Florida, and
`
`h.
`
`outside Florida but:
`
`(1) within the United States of America. its
`territories or possesstons or Canada, or
`(2) in Mexico within 50 miles of the United
`States border
`
`to you or a relative, while occupyingdyaur
`car, a newly ac aired car, a «awesome car,
`a tem orary su stimte car or a trailer which
`woul
`be covered at no additional charge
`under the Trailer Coverage provision of
`either of the iiability coverages.
`
`1:). while the insured vehicle is being shipped
`between their ports
`
`3. The death, dismemberment and loss of sight cov-
`erage you chose applies anywhere 1n the world.
`
`FINANCED VEHICLES
`
`Ifa creditor is shown in the declarations, we may pay
`any comprehenssve or collismn loss to:
`
`I. you and, if unpaid, the repairer; or
`
`2. you and such creditor,“ as its interest may
`appear, when we find it is n
