Merly Nunez v. Geico General Insurance Company

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[PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
FILED
U.S. COURT OF APPEALS
ELEVENTH CIRCUIT
APRIL 3, 2012
No. 10-13183
JOHN LEY
CLERK
D. C. Docket No. 1:09-cv-23624-JLK
MERLY NUNEZ,
a.k.a. Nunez Merly,
Plaintiff-Appellant,
versus
GEICO GENERAL INSURANCE COMPANY,
Defendant-Appellee.
Appeal from the United States District Court
for the Southern District of Florida
(April 3, 2012)
Before DUBINA, Chief Judge, FAY and KLEINFELD,* Circuit Judges.
*
Honorable Andrew J. Kleinfeld, United States Circuit Judge for the Ninth Circuit, sitting
by designation.
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DUBINA, Chief Judge:
Merly Nuñez, a class representative, appeals the district court’s dismissal of
her complaint for failure to state a claim and its order denying her motion for
reconsideration. Nuñez argues that examinations under oath (“EUOs”) are
impermissible conditions precedent to personal injury protection (“PIP”) coverage
under Florida law and the Florida No-Fault automobile insurance statute based on
the Florida Supreme Court’s decision in Custer Med. Ctr. v. United Auto. Ins. Co.,
62 So. 3d 1086, 1089 n.1, 1091 (Fla. 2010) (per curiam). Geico Insurance
Company insists that any statements regarding EUOs by the Florida Supreme
Court in Custer were merely dicta and not controlling. As a result of varying
interpretations of Custer in the lower Florida state courts, we conclude that Florida
law is unclear in the context of statutorily mandated insurance and the Florida No-
Fault Statute and certify this question to the Florida Supreme Court.
I.
Nuñez is the named plaintiff and class representative in this class action
brought pursuant to Florida Rule of Civil Procedure 1.220. Nuñez was in a car
accident on September 17, 2008, and suffered injuries. She has an insurance
policy with Geico that provides for PIP benefits. When she requested payment of
her medical bills pursuant to the terms of her insurance policy, Geico denied her
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coverage. She alleges that she was denied coverage because she failed to attend
an EUO. Geico asserts that an EUO is a prerequisite to receiving benefits under
its policy.
Nuñez filed a class action lawsuit asserting four counts against Geico. The
action was filed in state court on October 26, 2009, and removed to the United
States District Court for the Southern District of Florida on December 4, 2009,
under CAFA, 28 U.S.C. § 1332(d). On January 7, 2010, Geico filed a motion to
dismiss Nuñez’s complaint on all four counts under Federal Rule of Civil
Procedure 12(b)(6). The district court granted Geico’s motion to dismiss with
prejudice on April 13, 2010.
Nuñez filed a timely motion for reconsideration on May 11, 2010, which the
district court denied. Nuñez appeals the dismissal of count two only, which asked
the district court to determine whether Florida’s PIP Statute, FLA. STAT. §
627.736, permits EUOs as a prerequisite to receiving PIP benefits. The district
court found that there was no language in the PIP statute prohibiting an insurer
from requiring an EUO.
On September 8, 2011, Geico sent a letter to the Eleventh Circuit Clerk of
Court, pursuant to Federal Rule of Appellate Procedure 28(j), to advise this court
of supplemental authority. Geico asserts that two recent opinions from the
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Appellate Division of the Eleventh Judicial Circuit Court in and for Miami-Dade
County, Florida, impact Geico’s position in this appeal: State Farm Fire & Cas.
Co. v. Suncare Physical Therapy, Inc., No. 08-648 AP (Fla. Cir. Ct., July 13,
2011), and United Auto. Ins. Co. v. Diaz, 18 Fla. L. Weekly Supp. 348a (Fla. Cir.
Ct., Feb. 3, 2011). Both cases discuss Custer and come to different conclusions on
whether EUOs are permissible conditions precedent to the payment of PIP benefits
under automobile insurance policies. Geico filed a motion to certify the question
of Custer’s precedential value and effect to the Florida Supreme Court, and we
carried that motion with this case.
II.
“Where there is doubt in the interpretation of state law, a federal court may
certify the question to the state supreme court to avoid making unnecessary Erie1
guesses and to offer the state court the opportunity to interpret or change existing
law.” Auto–Owners Ins. Co. v. Se. Floating Docks, Inc., 632 F.3d 1195, 1197
(11th Cir. 2011) (quoting Tobin v. Mich. Mut. Ins. Co., 398 F.3d 1267, 1274 (11th
Cir. 2005) (per curiam)). Two unpublished Florida state court decisions decided
after the appeal in this case call into question the effect of the Florida Supreme
Court’s statements on EUOs in Custer.
1
Erie R.R. Co. v. Tompkins, 304 U.S. 64, 58 S. Ct. 817, 82 L. Ed. 1188 (1938).
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A. Custer Med. Ctr. v. United Auto. Ins. Co.
In Custer, the medical center provided treatment to a patient whose injuries
were covered under the PIP benefits of an automobile insurance policy. Custer,
62 So. 3d at 1089. After the treatment was complete and bills were submitted,
United Automobile Insurance Company scheduled two independent medical
examinations (“IMEs”) for the patient. Id. The patient did not appear for either
IME, and United denied the patient’s PIP benefits. Id. The Custer lawsuit had
nothing to do with EUOs but the court references an EUO in dictum in one
footnote:
The concept of a verbal examination under oath is not relevant
due to the posture of this case and positions of the parties. The
only argument in this case at the trial court, circuit court, and district
court of appeal was based upon medical exams and the failure to
attend medical exams. A purported verbal exam under oath
without counsel in the PIP context is invalid and more restrictive
than permitted by the statutorily mandated coverage and the terms
and limitations permitted under the statutory provisions. The
prohibition of policy exclusions, limitations, and non-statutory
conditions on coverage controlled by statute is clear.
...
PIP insurance is markedly different from homeowner's/tenants
insurance, property insurance, life insurance, and fire insurance,
which are not subject to statutory parameters and are simply a matter
of contract not subject to statutory requirements.
Id. at 1089, n.1 (citing Flores v. Allstate Ins. Co., 819 So. 2d 740, 745 (Fla. 2002))
(emphasis added). Since the reference to EUOs is in a footnote and the court itself
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states that EUOs are not relevant to the appeal in Custer, this footnote is obiter
dictum and not binding on any court.
An EUO is mentioned again in the procedural history and analysis sections
of the Custer decision when the court explains why United petitioned the Third
District Court of Appeals for certiorari. Custer, 62 So. 3d at 1091. The Florida
Supreme Court recognized that the circuit court appellate division quashed the
circuit court’s decision solely on the authority of two cases that were not
reconcilable: Griffin v. Stonewall Ins. Co., 346 So. 2d 97 (Fla. Dist. Ct. App.
1977), and Goldman v. State Farm Gen. Ins. Co., 660 So. 2d 300 (Fla. Dist. Ct.
App. 1995). The Florida Supreme Court clarified the cases:
In Griffin, the Third District considered the 1975 version of the PIP
statute, which did not include the “unreasonable refusal ” provision,
and held that an insured's failure to comply with the condition
precedent of attendance at a medical examination constituted grounds
to enter judgment for the insurer. Goldman involved a homeowner's
insurance policy and the insured's failure to attend an examination
under oath pursuant to the contractual terms of the policy, which has
no application in the statutorily required coverage context. The
Florida No–Fault statute is mandatory and does not recognize
such a condition. It is therefore invalid and contrary to the
statutory terms.
Id. (citations omitted) (emphasis added). The Florida Supreme Court was merely
outlining the complex procedural history of the case when it mentioned EUOs in
this context. However, in the footnote the court distinguished statutory PIP
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coverage—at issue in this case—from other types of insurance like homeowners,
fire, life, and property insurance that are based purely on contract. That comment,
along with the court’s suggestion that the no-fault statute is mandatory and does
not recognize an EUO as a condition precedent, puts the law in this area in
question.
Although the Florida Supreme Court’s statements on EUOs in Custer are
dicta, at least one Florida court finds the decision persuasive. See United Auto.
Ins. Co. v. Diaz, 18 Fla. L. Weekly Supp. 348a, at *5 (Fla. Cir. Ct., Feb. 3, 2011)
(relying on Custer and holding that an EUO cannot be a condition precedent to
payment of medical bills under a PIP insurance policy), but cf. State Farm Fire &
Cas. Co. v. Suncare Physical Therapy, Inc., No. 08-648 AP, at *5 (Fla. Cir. Ct.,
July 13, 2011) (finding that the EUO statements in Custer were dicta and could
not be relied upon as precedent and thus holding that EUOs are permissible
conditions precedent to the payment of PIP benefits under automobile insurance
policies in the State of Florida). To date, Diaz is the only Florida case that clearly
holds that an EUO cannot be a condition precedent to PIP recovery.
B. Florida’s No-Fault Statute
Under Florida’s No-Fault Statute, an insured is not expressly required to
attend an EUO as a condition precedent to bringing suit against an insurer to
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recover PIP benefits. See FLA. STAT. § 627.736. Likewise, there is no language in
the PIP statute prohibiting an insurer from requiring an EUO. Conditions not
expressly addressed in a statute governing insurance coverage are subject to a two
part test: (1) “whether the condition or exclusion unambiguously excludes or
limits coverage[;]” and (2) “whether enforcement of a specific provision would be
contrary to the purpose of the . . . statute.” Flores v. Allstate Ins. Co., 819 So. 2d
740, 745 (Fla. 2002).
As Geico points out, EUOs are consistent with many provisions in the No-
Fault Statute. Section 627.736(4) states that benefits from an insurer are “due and
payable as loss accrues, upon receipt of reasonable proof of such loss . . . .” FLA.
STAT. § 627.736(4) (emphasis added); see Amador v. United Auto Ins. Co., 748
So. 2d 307, 308 (Fla. Dist. Ct. App. 1999) (acknowledging that “reasonable proof”
could include the requirement that an insured submit to an EUO). Subsection
(4)(h) of the statute provides that benefits are not due under the statute if there is
evidence of fraud “admitted to in a sworn statement by the insured.” FLA. STAT. §
627.736(4)(h). Additionally, Section 627.414(3) expressly authorizes insurers to
include any “additional provisions not inconsistent with this code and which are . .
. [d]esired by the insurer and neither prohibited by law nor in conflict with any
provisions required to be included therein.” FLA. STAT. § 627.414(3).
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Geico argues that EUOs are permitted as conditions precedent to coverage
under the PIP statute because they meet the Flores test. Yet in Flores, the Florida
Supreme Court noted that in determining whether a condition not expressed in the
statute is valid, “analogies to cases interpreting coverages that are not statutorily
mandated, such as provisions in fire, life, and property insurance policies, may not
necessarily be illuminating in guiding our analysis [because both PIP and
uninsured motorist are statutorily mandated coverages].” Flores, 819 So. 2d at
745. Many of the cases cited by Geico in its brief, while in general support an
insurer’s right to require EUOs before payment, do not directly address the EUO
problem at issue because they do not involve statutorily required coverage.
C. Florida Case Law
Although we believe the Florida Supreme Court’s statements regarding
EUOs in Custer are dicta and not binding, Florida law is far from clear. Geico
points to Florida Supreme Court and intermediate appellate court decisions that
affirm the right of insurers to require an EUO in connection with its investigation
of a claim for PIP benefits. While there is a long history of Florida courts
generally affirming the right of an insured to require EUOs prior to payment of
benefits, these cases deal with insurance contracts not based on statute. See S.
Home Ins. Co. v. Putnal, 49 So. 922, 932 (Fla. 1909) (affirming that insured’s
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refusal to comply with fire insurance policy condition that insured submit to an
examination under oath precluded recovery); Edwards v. State Farm Fla. Ins. Co.,
64 So. 3d 730, 732 (Fla. Dist. Ct. App. 2011) (affirming summary judgment for
insurer on ground that insured failed to comply with pre-suit requirement of
submitting to EUO in property insurance contract); Gonzalez v. State Farm Fla.
Ins. Co., 65 So. 3d 608, 609 (Fla. Dist. Ct. App. 2011) (same); Goldman v. State
Farm Fire Gen. Ins. Co., 660 So. 2d 300, 303 (Fla. Dist. Ct. App. 1995) (affirming
that “an insured’s refusal to comply with a demand for an examination under oath
is a willful and material breach of [a homeowner’s] insurance contract which
precludes the insured from recovery under the policy”).
Because the court in Custer suggested that an EUO is not a condition
precedent to PIP coverage and distinguished EUO cases under PIP with statutorily
mandated coverage from other types of coverage that are not statutorily mandated,
the decision suggests that an EUO is not a condition precedent to PIP coverage.
Absent a clear decision from the Florida Supreme Court on this issue, “we are
bound to follow decisions of the state’s intermediate appellate courts unless there
is some persuasive indication that the highest court of the state would decide the
issue differently.” McMahan v. Toto, 311 F.3d 1077, 1080 (11th Cir. 2002). The
Florida Supreme Court has specifically approved this rule by holding that “[t]he
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decisions of the district courts of appeal represent the law of Florida unless and
until they are overruled by [the Florida Supreme Court].” Id. (quoting Pardo v.
State, 596 So. 2d 665, 666 (Fla. 1992)).
The Florida appellate courts have not decisively ruled on this issue. The
only case that discusses the right of an insurer to require the insured to submit to
an EUO in the statutory context as a condition precedent to coverage is Shaw v.
State Farm Fire & Cas. Co., 37 So. 3d 329 (Fla. Dist. Ct. App. 2010) (en banc),
decided six months before Custer. In Shaw, the issue before the court was
whether an EUO clause in an automobile insurance policy was binding on an
assignee of the right to payment of no-fault benefits, and the court held that an
assignee medical provider is not required to submit to an EUO. Id. at 335. Before
reaching that conclusion, the court stated that “[i]t is undisputed that a provision in
an insurance policy that requires the insured to submit to an EUO qualifies as a
condition precedent to recovery of policy benefits.” Id. at 331. Because the
decision was not unanimous and the court thought the issue had a wide-ranging
impact, the court certified the following question to the Florida Supreme Court:
“Whether a health care provider who accepts an assignment of no-fault insurance
proceeds in payment of services provided to an insured can be required by a
provision in the policy to submit to an examination under oath as a condition to
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the right of payment?” Id. at 335. That question has not yet been answered by the
Florida Supreme Court.
The court in Shaw clearly stated that an EUO is a condition precedent to
recovery of benefits if the insurance policy requires the insured to submit to an
EUO. Id. at 331. However, the court did not distinguish the statutory coverage at
issue in that case from other types of insurance like the Florida Supreme Court did
in dicta in Custer. Indeed, the court in Shaw cited the same cases Geico relies on
here to support the position that EUOs are valid conditions precedent under
Florida law, none of which directly apply to statutorily-imposed coverage. Based
on the dicta in Custer, it could be that the Florida Supreme Court may not follow
the appellate court’s statement in Shaw. The interpretation of the Florida No-Fault
Statute is a question of state law that has not been specifically addressed by the
Florida Supreme Court or the intermediate state appellate courts.
III.
For the foregoing reasons, we delay final judgment in this case until the
Florida Supreme Court has had an opportunity to consider whether an insurer can
require an insured to submit to an EUO as a condition precedent to recovery of PIP
benefits under the Florida No-Fault Statute. Rather than attempting an Erie
“guess” as to how the Florida Supreme Court would rule on this issue, we certify
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the following question to the Florida Supreme Court, pursuant to Fla. Const. art.
V, § 3(b)(6). See Pendergast v. Sprint Nextel Corp., 592 F.3d 1119, 1143 (11th
Cir. 2010):
Whether, under FLA. STAT. § 627.736, an insurer can require an
insured to attend an EUO as a condition precedent to recovery of PIP
benefits?
The answer to this question will assist this court in determining whether
Nuñez was required to submit to an EUO prior to filing suit against Geico. To
facilitate the resolution of this question, we direct the Clerk to transmit the entire
record of this case, together with copies of the parties’ briefs, to the Florida
Supreme Court. Of course, the Florida Supreme Court is in no way limited by our
question and may consider the case as it sees fit.
QUESTION CERTIFIED.
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