UNITED AUTOMOBILE INSURANCE COMPANY v. CHIROPRACTIC CLINICS OF SOUTH FLORIDA, PL, A/A/O MICHAEL AKINS ( 2021 )

Third District Court of Appeal
State of Florida
Opinion filed June 16, 2021.
Not final until disposition of timely filed motion for rehearing.
________________
No. 3D21-111
Lower Tribunal Nos. 20-89 AP, 17-6492 CC
________________
United Automobile Insurance Company,
a Florida corporation,
Appellant,
vs.
Chiropractic Clinics of South Florida, PL
a/a/o Michael Akins,
Appellee.
An Appeal from the County Court for Miami-Dade County, Gloria
Gonzalez-Meyer, Judge.
Michael J. Neimand, for appellant.
Douglas H. Stein, P.A., and Douglas H. Stein, for appellee.
Before FERNANDEZ, HENDON, and BOKOR, JJ.
HENDON, J.
United Automobile Insurance Company (“United Auto”) appeals from
a final summary judgment. We affirm.
In March 2014, Michael Akins (“Akins”) was a passenger in a vehicle
involved in an accident. The driver was the sister of the owner of the vehicle,
which was covered by a policy issued to the owner by United Auto. On April
30, 2014, Akins appeared for an examination under oath conducted by
United Auto. He testified in that deposition that he had lived at 2747 N.W.
131st Street, Miami, Florida, for the past seven years with his mother,
Dorothy Akins, who did not have a driver's license. 1
On May 28, 2014, United Auto sent a letter to Akins' attorney denying
PIP coverage to Akins. United Auto explained that it denied coverage
because the adjuster performed a statewide auto and insurance database
search and concluded that, contrary to Akins’ statement, Akins lived with a
"Dorothy M. Akins" with an address of 10145 S.W. 171st Street, Miami,
Florida, who owned a car insured by Infinity Insurance Company. A later
statewide database search revealed that a "Dorothy A. Akins" lived at 2747
1
If there are no motor vehicles in the victim's household, the injured party is
covered by the policy covering the vehicle in which he or she was riding at
the time of the accident. See Shivers v. Enter. Leasing Co., 950 So. 2d 494(Fla. 4th DCA 2007).
2
N.W. 131st Street, Miami, Florida, and that she did not have a driver's
license, as Akins indicated in his deposition.
On April 7, 2014, after United Auto had denied PIP coverage, Akins
went to Chiropractic Clinic of South Florida (“CCSF”) for treatment, and
based on United Auto's denial of coverage, advised CCSF that he did not
have PIP insurance coverage. 2 CCSF had Akins execute a letter of
protection and treated him. On January 12, 2015, Akins’ attorney advised
United Auto that it was mistaken as to coverage and was actually the insurer.
On that same day, CCSF sent its bill to United Auto.
On August 8, 2017, CCSF filed its complaint against United Auto as
Akins' assignee asserting two counts: Breach of Contract, and Declaratory
Judgment seeking a declaration that Akins is covered by United Auto's
insurance policy. United Auto denied all relevant allegations and raised the
affirmative defense that CCSF failed to timely submit its medical bill within
thirty-five days of the medical services having been rendered, as required by
section 627.736(5)(c), Florida Statutes. CCSF denied the affirmative
defense based on equitable estoppel, waiver, and lack of prejudice.
2
The purpose of PIP benefits is to provide up to $10,000 for medical bills
and lost wages without regard to fault. See, e.g., §§ 627.731, 627.736, Fla.
Stat. (2020). PIP benefits are an integral part of the no-fault statutory
scheme. Flores v. Allstate Ins. Co., 819 So. 2d 740, 744 (Fla. 2002).
3
In June 2018, during discovery, Dorothy M. Akins stated that she
owned a car insured by Infinity Insurance, was not Akins’ mother, did not
know Akins, and did not live at the address Akins provided in his deposition
as his mother’s address. Despite United Auto’s error, it continued to deny
Akins PIP coverage until November 2018. On November 18, 2018, United
Auto conceded that Akins was covered by its PIP policy but maintained that
CCSF’s late billing precluded payment.
Both parties submitted motions for summary judgment and stipulated
no facts were in dispute. United Auto also stipulated to the reasonableness
of CCSF’s charges. The only issue was United Auto’s late billing defense.
The trial court held a hearing, 3 denied United Auto’s motion for summary
judgment, made findings of fact and conclusions of law, and granted CCSF’s
cross-motion for summary judgment. United Auto appeals.
Our standard of review is de novo. Volusia Cnty. v. Aberdeen at
Ormond Beach, L.P., 760 So. 2d 126 (Fla. 2000).
Discussion
Section 627.736(5)(c)(l)(a) and (b) provides, in relevant part:
(c) With respect to any treatment or service, other than medical
services billed by a hospital or other provider for emergency
services and care as defined ins. 395.002 or inpatient services
3
There is no transcript of the summary judgment hearing in the record on
appeal.
4
rendered at a hospital-owned facility, the statement of charges
must be furnished to the insurer by the provider and may not
include, and the insurer is not required to pay, charges for
treatment or services rendered more than 35 days before the
postmark date or electronic transmission date of the statement, .
..
1. If the insured fails to furnish the provider with the correct
name and address of the insured's personal injury protection
insurer, the provider has 35 days from the date the provider
obtains the correct information to furnish the insurer with a
statement of the charges. The insurer is not required to pay
for such charges unless the provider includes with the
statement documentary evidence that was provided by the
insured during the 35-day period demonstrating that the
provider reasonably relied on erroneous information from the
insured and either:
a. A denial letter from the incorrect insurer; or
b. Proof of mailing, which may include an affidavit under
penalty of perjury, reflecting timely mailing to the incorrect
address or insurer.
(Emphasis added). United Auto argues that pursuant to section
627.736(5)(c)1a. and b., it is not responsible for paying CCSF, the provider,
because Akins gave CCSF the wrong information when he told CCSF that
he did not have PIP coverage. United Auto argues that, as a result of Akins’
erroneous statement to CCSF, CCSF relied on that information and did not
timely bill United Auto. United Auto argues that even if the provider billing
exception in 1.a and b applies, CCSF did not provide a denial letter or a
statement that it reasonably relied on Akins’ erroneous information.
5
When all permissible inferences are viewed in a light most favorable to
CCSF on United Auto’s motion for summary judgment, considering that
Akins and CCSF relied to their detriment on United Auto’s denial of
coverage, we conclude that the principles of equitable estoppel apply. See,
e.g., Glantzis v. State Auto. Mut. Ins. Co., 573 So. 2d 1049, 1051 (Fla. 4th
DCA 1991) (finding insurer was equitably estopped from relying upon the
statute of limitations because of its conduct); Pro. Underwriters Ins. Co. v.
Freytes & Sons Corp., 565 So. 2d 900, 902 (Fla. 5th DCA 1990) (holding the
general rule in applying equitable estoppel to insurance contracts provides
that estoppel may be used defensively to prevent a forfeiture of insurance
coverage); Bishop v. Progressive Exp. Ins. Co., 154 So. 3d 467, 468 (Fla.
1st DCA 2015) (holding “coverage by estoppel” requires a representation of
material fact, reasonable reliance, and a detrimental change in position (i.e.,
prejudice) as a result of the reliance, which are generally questions for the
trier of fact.”).
The elements necessary for application of equitable estoppel are: “(1)
a representation as to a material fact that is contrary to a later-asserted
position; (2) reliance on that representation; and (3) a change in position
detrimental to the party claiming estoppel caused by the representation and
reliance thereon.” Council Bros., Inc. v. City of Tallahassee, 634 So. 2d 264,
6
266 (Fla. 1st DCA 1994) (quoting Dep't of Revenue v. Anderson, 403 So. 2d
397, 400 (Fla. 1981)). Generally, estoppel may only be applied in cases of
misrepresentations of fact, not misstatements of law. Id. at 266. Hamilton
Downs Horsetrack, LLC v. State Dep't of Bus. & Pro. Regul., Div. of Pari-
Mutuel Wagering, 226 So. 3d 1046, 1051 (Fla. 1st DCA 2017). Equitable
estoppel is based on principles of fair play and essential justice and arises
when, as in this case, one party lulls another party into a disadvantageous
legal position. The doctrine of equitable estoppel is, as the Florida Supreme
Court stated, “applicable in all cases where one, by word, act or conduct,
willfully caused another to believe in the existence of a certain state of things,
and thereby induces him to act on this belief injuriously to himself, or to alter
his own previous condition to his injury.” State ex rel. Watson v. Gray, 48 So.
2d 84, 87–88 (Fla.1950) (quoting 3 Pomeroy's Equity Jurisprudence § 804
(5th ed.1941)).
Equitable estoppel presupposes a legal shortcoming in a party's case
that is directly attributable to the opposing party's misconduct. The doctrine
bars the wrongdoer from asserting that shortcoming and profiting from his or
her own misconduct. Equitable estoppel thus functions as a shield, not a
sword, and operates against the wrongdoer, not the victim. Major League
Baseball v. Morsani, 790 So. 2d 1071, 1076–77 (Fla. 2001) (citations
7
omitted). The doctrine has been recognized as a valid defense to a
limitations-period defense. Id.; see also Noble v. Yorke, 490 So. 2d 29, 31
(Fla. 1986) (holding absent specific statutory provision, there is no rule of
law which in general exempts statutory rights and defenses from the
operation of the doctrine of equitable estoppel).
Through no fault of his own, Akins was advised by United Auto that he
was not covered by PIP, and relying on this information he told CCSF that
he had no PIP coverage. Neither Akins nor CCSF discovered United Auto’s
error until January 2015, and CCSF sent its bill to United Auto within thirty-
five days of that discovery. Despite this, United Auto continued to deny
coverage until November 2018, months after discovery revealed that United
Auto had based its denial of coverage on the wrong Dorothy Akins. The
problem is one of United Auto’s making, not Akins’ or CCSF’s.
United Auto denied Akins had PIP coverage based on United Auto’s
faulty research –not, as United Auto asserts, on Akins’ failure to provide
accurate information. Once forced to concede its error, United Auto changed
its tactic, and sought to avoid coverage by arguing CCSF failed to submit its
bill within the statutory thirty-five days from provision of services. This is a
circumstance in which equitable estoppel applies in order to avoid an
unreasonable and unjust result. We conclude, on de novo review, that
8
United Auto was properly estopped from denying coverage based on its own
conduct.
Affirmed.
9