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Green v. State Farm Mutual Automobile Insurance Company

Jun 22, 2017 in Case Law Updates by

In a class action PIP case involving an automobile insurer determined PIP benefit reimbursement, the Fourth District Court of Appeal held that it is appropriate for a Plaintiff to seek declaratory relief in order to determine if State Farm relied exclusively on the fee schedule to determine payment reimbursement.         

Plaintiff requested that State Farm be ordered to reimburse class members for the amounts that they were billed by their providers. Plaintiff alleged in her Complaint that despite State Farm not electing to reimburse medical providers by the Medicare Fee Schedule method in her policy, State Farm relied exclusively on the Medicare Fee Schedules as the basis to determine a reasonable amount for reimbursement subjecting the class members to balance-billing.

State Farm moved to dismiss the Complaint claiming that Plaintiff failed to state a claim, as State Farm did not elect to use the Medicare Fee Schedule. Although the trial court agreed with State Farm’s position, the Fourth District Court of Appeal reversed.

The Court looked to its prior decision in Northwest Center for Integrated Medicine and Rehabilitation, Inc. v. State Farm Mut. Auto. Ins. Co. quoting “the test of the sufficiency of a Complaint in a declaratory judgment proceeding is not whether the Complaint shows that the Plaintiff will succeed in getting a declaration of rights in accordance with his theory and contention, but whether he is entitled to a declaration of rights at all.” In Northwest, this Court held that the proper methodology for calculating reimbursement under sub-section (5)(a)(1) and whether the Medicare Fee Schedules could be solely relied had not been addressed by prior cases. In that case, the Court reversed the trial court’s decision to dismiss for lack of cause of action, and the same principles are applied in this case.

 As such, Plaintiff is given leave to amend her claim after remand for declaratory relief to similar to that approved in Northwest. In regards to the relief requested by Plaintiff, the Court held that the request was inappropriate because she constructively agreed to balance-billing in her policy as State Farm did not elect to use the fee schedule, and therefore it must be amended.


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