When Danielle Russell was injured in an accident, she was treated by a chiropractic business called Randy Rosenberg, DC, PA. Afterwards, Geico did not pay the entire amount of her bills, even though they were lower than her coverage limits. The dispute in this class action revolves around how much Geico General Insurance Company pays for medical bills under personal injury protection (PIP) coverage.
Both Russell and Randy Rosenberg are located in Florida. The Geico policy has a form Endorsement with the code FLPIP (01-13).
Florida’s No-Fault Law (PIP statute) requires drivers to have personal injury protection (PIP) coverage to pay for medical bills and lost wages in event of injuries in an accident. The law requires that PIP insurers pay “eighty percent of all reasonable expenses for medically necessary medical” treatment. Insurers are allowed to use the Medicare Part B participating provider fee schedule as a guide to a “reasonable amount” for medical treatments.
The law says that charges “may not exceed the amount the person or institution customarily charges for like services or supplies.” It also says, “The insurer may limit reimbursement to 80 percent of” a certain schedule of “maximum charges[.]” The law does not permit insurance companies to pay less than these amounts, although they may pay more.
In the Endorsement to Russell’s policy, Geico chose the use of certain fee schedules but added the following statement: “A charge submitted by a provider, for an amount less than the amount allowed above, shall be paid in the amount of the charge submitted.”
Russell’s bills from Randy Rosenberg were less than the amounts allowed. However, when those bills were submitted, Geico paid only 80% of their amounts.
For example, treatment under CPT code 99214 was $175. This amount is less than the maximum amount in the fee schedule chosen in the Endorsement. However, Geico paid only $140. Another item of $80 was submitted under CPT code 98941. This was also less than the amount in the chosen fee schedule. But Geico paid only $64.
Geico provided and Explanation of Review with the code BA for the items where it paid less than the full amount. That code, the complaint says, shows that Geico paid only 80% of the charge.
Randy Rosenberg’s central allegation in this case is that, since those bills were less than the maximum amount on the fee schedule, they should have been paid at 100%.
The class for this action is all health providers who, within the statute of limitations, received an assignment of benefits from a claimant and then submitted claims for no-fault benefits, under Geico policies to which FLPIP (01-13) applies, or subsequent policies with similar language that were in effect since January 1, 2013, where Geico used the Explanation Code BA with respect to the payment of claims.