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Case Number: CONO-20-019655 Division: 70
Filing # 115388102 E-Filed 10/21/2020 04:42:50 PM
IN THE COUNTY COURT IN AND FOR
BROWARD COUNTY, FLORIDA
CIVIL DIVISION
MD NOW MEDICAL CENTERS, INC. d/b/a MD NOW
(Patient: Stephanie Degraaf), CASE NO:
Plaintiff,
vs.
GEICO GENERAL INSURANCE COMPANY,
Defendant.
/
COMPLAINT FOR DECLARATORY RELIEF
The Plaintiff, MD NOW MEDICAL CENTERS, INC. d/b/a MD NOW (Patient: Stephanie
Degraaf), (hereinafter "Plaintiff"), sues the Defendant, GEICO GENERAL INSURANCE COMPANY,
(hereinafter "Defendant"), and alleges:
THE PARTIES JURISDICTION AND VENUE
1. This is an action for declaratory judgment, pursuant to Florida Statutes, Chapter 86,
with respect to the interpretation, rights, obligations, and/or exclusions of the PIP coverage under
the automobile insurance policy and F.S. Section 627.736.
2. At all times material hereto, Plaintiff was a medical provider properly licensed to
transact business in the State of Florida.
3. Defendant is a corporation licensed to transact business in the State of Florida.
Venue is proper in Broward County as Defendant maintains agents for the customary transacting of
business in Broward County.
4. On or about September 12, 2019, Stephanie Degraaf, was involved in a motor vehicle
accident and sustained personal injuries.
5. The Defendant is on notice of this claim and has assigned claim number
0591841230000001 to the claim.
6. As a direct and proximate result of the injuries Insured sustained in the accident, the
patient incurred reasonable expenses for necessary medical care.
*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 10/21/2020 04:42:48 PM.****7. Plaintiff provided reasonable and necessary medical care, treatment and/or
rehabilitative care to Stephanie Degraaf on 09/13/2019. Plaintiff submitted bills to the Defendant for
the above date(s) of treatment.
8. Plaintiff billed Defendant for the medical services and care provided to the patient.
9. Defendant issued a policy of insurance which provided personal injury protection
benefits, and/or medical and extended medical expense coverage. Plaintiff does not have a copy of
the policy to attach but Defendant is in possession of the original policy.
10. | The above described policy was in full force and effect on the date of the accident
and provided PIP coverage and medical expense coverage for Insured for bodily injuries sustained
in said accident.
11. That claimant, Stephanie Degraaf, has assigned all rights and benefits under the
policy to the Plaintiff by oral assignment, equitable assignment and/or written assignment of
benefits.
12. Plaintiff as an assigned beneficiary under the contract of insurance in favor of the
Insured is entitled to bring this action.
COUNT I
DECLARATORY RELIEF
13. Plaintiff realleges paragraphs one (1) through twelve (12), as if fully stated herein.
14. Plaintiff billed defendant for medical services and care on the above referenced date
of service.
15. Defendant provided an Explanation of Review to Plaintiff and the patient reflecting
reimbursement at less than 80% of 200% of the participating physician fee schedule of Medicare
Part B for medical treatment, services, and care billed by Plaintiff. It is Defendant’s contention that
its insurance policy elected to limit reimbursement pursuant to the schedule of maximum charges,
specifically 200% of the participating physician fee schedule of Medicare Part B. In this case,
Defendant limited reimbursement to less than 80% of 200% of the participating physician fee
schedule of Medicare Part B.16. Further, Defendant issued a Fee Schedule Endorsement M 608 (01-13), as part of its
policy, which provides as follows:
IMPORTANT NOTICE
FEE SCHEDULE ENDORSEMENT
USE OF MEDICAL FEE SCHEDULE FOR PERSONAL INJURY PROTECTION CLAIMS
THIS NOTICE IS ENCLOSED IN COMPLIANCE WITH FLORIDA STATUTE 627.736
Effective January 1, 2013
The Company will limit reimbursement of medical expenses to 80 percent of a properly billed
reasonable charge, but in no event will the Company pay more than 80 percent of the following
schedule of maximum charges:
1. For emergency transport and treatment by providers licensed under Chapter 401,
Florida Statutes, 200 percent of Medicare.
2. For emergency services and care provided by a hospital licensed under Chapter 395,
Florida Statutes, 75 percent of the hospital’s usual and customary charges.
3. For emergency services and care as defined by Florida Statutes § 395.002 provided in
a facility licensed under Chapter 395, Florida Statutes rendered by a physician or dentist,
and related hospital inpatient services rendered by a physician or dentist, the usual and
customary charges in the community.
4. For hospital inpatient services, other than emergency services and care, 200 percent
of the Medicare Part A prospective payment applicable to the specific hospital providing
the inpatient services.
5. For hospital outpatient services, other than emergency services and care, 200 percent
of the Medicare Part A Ambulatory Payment Classification for the specific hospital
providing the outpatient services.
6. For all other medical services, supplies, and care, 200 percent of the allowable amount
under:
(I.) The participating physicians fee schedule of Medicare Part B, except as provided in
sections (II.) and (Ill.)
(II.) Medicare Part B, in the case of services, supplies, and care provided by ambulatory
surgical centers and clinical laboratories.
(Ill.)The Durable Medical Equipment Prosthetics/Orthotics and Supplies fee schedule of
Medicare Part B, in the case of durable medical equipment.
However, if such services, supplies, or care is not reimbursable under Medicare Part B
(as provided in section 6. above), we will limit reimbursement to eighty percent (80%) of
the maximum reimbursable allowance under workers’ compensation, as determined
under Florida Statutes, § 440.13 and rules adopted thereunder which are in effect at the
time such services, supplies, or care is provided. Services, supplies, or care that is not
reimbursable under Medicare or workers’ compensation is not required to be reimbursed
by us.
17. Plaintiff is in doubt as to its rights under the F.S. 627.736 with respect to whether
Defendant may issue payment at less than 80% of 200% of the participating physician fee schedule
of Medicare Part B.
18. Plaintiff has been placed in doubt as to its rights under F.S. 627.736 and the
insurance policy endorsements and is in need of immediate judicial determination of those rights.19. There is a bona fide, actual, present practical need for the declaration of which
Defendant is required to provide reimbursement under the policy of insurance, policy endorsements,
and F.S. 627.736.
20. The declaration sought by the Plaintiff in this action deals with present, ascertained or
ascertainable state of facts or present controversy as to a state of facts regarding insurance
coverage.
21. Some immunity, power, privilege, or right of the Plaintiff is dependent on fact and/or
law applicable to the facts.
22. The Plaintiff has, or reasonably may have actual, present, adverse and antagonistic
interest in the subject matter, either in fact or law.
23. The antagonistic and adverse interest are all before the Court by proper process, and
the relief being sought is not merely giving of legal advice by this Court, or the answer to questions
propounded from curiosity, but deals with this Court’s determination of which Defendant is required
to provide insurance coverage.
24. The Plaintiff has retained the undersigned law firm to act on their behalf on this
Declaratory Action. Plaintiff sees and is entitled to an award of reasonable attorney's fees and costs
for the necessity of bringing this action pursuant to Florida Statute §627.736(5) and (8), §627.428,
and Florida Law.
WHEREFORE, THE PLAINTIFF RESPECTFULLY REQUESTS:
A. That the Court issue a declaratory judgment that, as a matter of law as to the proper
payment methodology that Defendant is to reimburse the medical services at 80% of 200 percent of
the allowable amount under the participating physician fee schedule of Medicare Part B.
B. That the Court determine and declare any other material matters pertaining to the
coverage or otherwise as to the respective rights and responsibilities of the party under the policy as
needed and retain jurisdiction to order any supplemental relief as may be necessary to do complete
justice in this matter and between the parties.C. Plaintiff seeks declaratory relief pursuant to F.S. §86.011 et seq. and further demands
attorney's fees pursuant to F.S. §627.428 and F.S. §627.736 (5) and (8), legal assistant fees
pursuant to F.S. §57.104 and costs pursuant to F.S. §92.231 and F.S. §57.041. The Plaintiff further
demands trial by Jury of all the issues so triable.Plaintiff Demands Trial by Jury.
Dated on October 21, 2020.
By:
GED LAWYERS, LLP
7171 North Federal Highway
Boca Raton, FL 33487
Telephone: (561) 995-1966
Facsimile: (561) 241-0812
Designated Email: service@gedlawyers.com
Attorneys for the Plaintiff
/s/Chad L. Christensen
Chad L. Christensen, Esq.
Florida Bar No.: 0468592
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Case Number: CONO-20-019655 Division: 70 Filing # 115388102 E-Filed 10/21/2020 04:42:50 PM IN THE COUNTY COURT IN AND FOR BROWARD COUNTY, FLORIDA CIVIL DIVISION MD NOW MEDICAL CENTERS, INC. d/b/a MD NOW (Patient: Stephanie Degraaf), CASE NO: Plaintiff, vs. GEICO GENERAL INSURANCE COMPANY, Defendant. / COMPLAINT FOR DECLARATORY RELIEF The Plaintiff, MD NOW MEDICAL CENTERS, INC. d/b/a MD NOW (Patient: Stephanie Degraaf), (hereinafter "Plaintiff"), sues the Defendant, GEICO GENERAL INSURANCE COMPANY, (hereinafter "Defendant"), and alleges: THE PARTIES JURISDICTION AND VENUE 1. This is an action for declaratory judgment, pursuant to Florida Statutes, Chapter 86, with respect to the interpretation, rights, obligations, and/or exclusions of the PIP coverage under the automobile insurance policy and F.S. Section 627.736. 2. At all times material hereto, Plaintiff was a medical provider properly licensed to transact business in the State of Florida. 3. Defendant is a corporation licensed to transact business in the State of Florida. Venue is proper in Broward County as Defendant maintains agents for the customary transacting of business in Broward County. 4. On or about September 12, 2019, Stephanie Degraaf, was involved in a motor vehicle accident and sustained personal injuries. 5. The Defendant is on notice of this claim and has assigned claim number 0591841230000001 to the claim. 6. As a direct and proximate result of the injuries Insured sustained in the accident, the patient incurred reasonable expenses for necessary medical care. *** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 10/21/2020 04:42:48 PM.****7. Plaintiff provided reasonable and necessary medical care, treatment and/or rehabilitative care to Stephanie Degraaf on 09/13/2019. Plaintiff submitted bills to the Defendant for the above date(s) of treatment. 8. Plaintiff billed Defendant for the medical services and care provided to the patient. 9. Defendant issued a policy of insurance which provided personal injury protection benefits, and/or medical and extended medical expense coverage. Plaintiff does not have a copy of the policy to attach but Defendant is in possession of the original policy. 10. | The above described policy was in full force and effect on the date of the accident and provided PIP coverage and medical expense coverage for Insured for bodily injuries sustained in said accident. 11. That claimant, Stephanie Degraaf, has assigned all rights and benefits under the policy to the Plaintiff by oral assignment, equitable assignment and/or written assignment of benefits. 12. Plaintiff as an assigned beneficiary under the contract of insurance in favor of the Insured is entitled to bring this action. COUNT I DECLARATORY RELIEF 13. Plaintiff realleges paragraphs one (1) through twelve (12), as if fully stated herein. 14. Plaintiff billed defendant for medical services and care on the above referenced date of service. 15. Defendant provided an Explanation of Review to Plaintiff and the patient reflecting reimbursement at less than 80% of 200% of the participating physician fee schedule of Medicare Part B for medical treatment, services, and care billed by Plaintiff. It is Defendant’s contention that its insurance policy elected to limit reimbursement pursuant to the schedule of maximum charges, specifically 200% of the participating physician fee schedule of Medicare Part B. In this case, Defendant limited reimbursement to less than 80% of 200% of the participating physician fee schedule of Medicare Part B.16. Further, Defendant issued a Fee Schedule Endorsement M 608 (01-13), as part of its policy, which provides as follows: IMPORTANT NOTICE FEE SCHEDULE ENDORSEMENT USE OF MEDICAL FEE SCHEDULE FOR PERSONAL INJURY PROTECTION CLAIMS THIS NOTICE IS ENCLOSED IN COMPLIANCE WITH FLORIDA STATUTE 627.736 Effective January 1, 2013 The Company will limit reimbursement of medical expenses to 80 percent of a properly billed reasonable charge, but in no event will the Company pay more than 80 percent of the following schedule of maximum charges: 1. For emergency transport and treatment by providers licensed under Chapter 401, Florida Statutes, 200 percent of Medicare. 2. For emergency services and care provided by a hospital licensed under Chapter 395, Florida Statutes, 75 percent of the hospital’s usual and customary charges. 3. For emergency services and care as defined by Florida Statutes § 395.002 provided in a facility licensed under Chapter 395, Florida Statutes rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community. 4. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services. 5. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services. 6. For all other medical services, supplies, and care, 200 percent of the allowable amount under: (I.) The participating physicians fee schedule of Medicare Part B, except as provided in sections (II.) and (Ill.) (II.) Medicare Part B, in the case of services, supplies, and care provided by ambulatory surgical centers and clinical laboratories. (Ill.)The Durable Medical Equipment Prosthetics/Orthotics and Supplies fee schedule of Medicare Part B, in the case of durable medical equipment. However, if such services, supplies, or care is not reimbursable under Medicare Part B (as provided in section 6. above), we will limit reimbursement to eighty percent (80%) of the maximum reimbursable allowance under workers’ compensation, as determined under Florida Statutes, § 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided. Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by us. 17. Plaintiff is in doubt as to its rights under the F.S. 627.736 with respect to whether Defendant may issue payment at less than 80% of 200% of the participating physician fee schedule of Medicare Part B. 18. Plaintiff has been placed in doubt as to its rights under F.S. 627.736 and the insurance policy endorsements and is in need of immediate judicial determination of those rights.19. There is a bona fide, actual, present practical need for the declaration of which Defendant is required to provide reimbursement under the policy of insurance, policy endorsements, and F.S. 627.736. 20. The declaration sought by the Plaintiff in this action deals with present, ascertained or ascertainable state of facts or present controversy as to a state of facts regarding insurance coverage. 21. Some immunity, power, privilege, or right of the Plaintiff is dependent on fact and/or law applicable to the facts. 22. The Plaintiff has, or reasonably may have actual, present, adverse and antagonistic interest in the subject matter, either in fact or law. 23. The antagonistic and adverse interest are all before the Court by proper process, and the relief being sought is not merely giving of legal advice by this Court, or the answer to questions propounded from curiosity, but deals with this Court’s determination of which Defendant is required to provide insurance coverage. 24. The Plaintiff has retained the undersigned law firm to act on their behalf on this Declaratory Action. Plaintiff sees and is entitled to an award of reasonable attorney's fees and costs for the necessity of bringing this action pursuant to Florida Statute §627.736(5) and (8), §627.428, and Florida Law. WHEREFORE, THE PLAINTIFF RESPECTFULLY REQUESTS: A. That the Court issue a declaratory judgment that, as a matter of law as to the proper payment methodology that Defendant is to reimburse the medical services at 80% of 200 percent of the allowable amount under the participating physician fee schedule of Medicare Part B. B. That the Court determine and declare any other material matters pertaining to the coverage or otherwise as to the respective rights and responsibilities of the party under the policy as needed and retain jurisdiction to order any supplemental relief as may be necessary to do complete justice in this matter and between the parties.C. Plaintiff seeks declaratory relief pursuant to F.S. §86.011 et seq. and further demands attorney's fees pursuant to F.S. §627.428 and F.S. §627.736 (5) and (8), legal assistant fees pursuant to F.S. §57.104 and costs pursuant to F.S. §92.231 and F.S. §57.041. The Plaintiff further demands trial by Jury of all the issues so triable.Plaintiff Demands Trial by Jury. Dated on October 21, 2020. By: GED LAWYERS, LLP 7171 North Federal Highway Boca Raton, FL 33487 Telephone: (561) 995-1966 Facsimile: (561) 241-0812 Designated Email: service@gedlawyers.com Attorneys for the Plaintiff /s/Chad L. Christensen Chad L. Christensen, Esq. Florida Bar No.: 0468592