State Farm Mutual Automobile Insurance Company v. Reidy Williams

Case: 12-11840 Date Filed: 04/15/2014 Page: 1 of 14
[PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
Nos. 12-11840; 12-15331
________________________
D.C. Docket No. 6:06-cv-01757-DAB
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY,
STATE FARM FIRE AND CASUALTY COMPANY,
Plaintiffs - Counter Defendants - Appellants,
versus
REIDY WILLIAMS,
EARL BYERS,
Intervenor Defendants - Counter Claimants - Appellees,
JERLEAN REED,
Intervenor Defendant - Consol. Counter Claimant -
Counter Claimant - Appellee.
________________________
Appeals from the United States District Court
for the Middle District of Florida
________________________
(April 15, 2014)
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Before TJOFLAT, FAY, and ALARCÓN, * Circuit Judges.
PER CURIAM:
This is the second appeal arising from a scheme by Physicians Injury Care
Center, Inc. (“PICC”) to submit fraudulent insurance claims to State Farm Mutual
Automobile Insurance Company and State Farm Fire and Casualty Company
(collectively, “State Farm”). Reidy Williams, Earl Byers, and Jerlean Reed
(collectively, “Intervenors”) intervened and alleged that, when State Farm stopped
paying the fraudulent bills submitted by PICC, it did not comply with the statutory
requirements to withdraw their Florida Personal Injury Protection (“PIP”)
insurance benefits. An intervening change in controlling authority causes us to
depart from our previous opinion and reinstate the jury verdict in its entirety.
I. BACKGROUND
A. PICC’s Fraud
State Farm sued PICC in November 2006 and alleged it had “unlawfully
obtained personal injury protection benefits . . . from State Farm by push[ing] State
Farm’s insureds through a sham course of treatment and evaluation designed
specifically to exhaust the patients’ insurance benefits.” State Farm Mut. Auto.
Ins. Co. v. Physicians Injury Care Ctr., Inc. (PICC), 427 F. App’x 714, 717 (11th
Cir. 2011) (internal quotation marks omitted). State Farm presented extensive
*
Honorable Arthur L. Alarcón, United States Circuit Judge for the Ninth Circuit, sitting
by designation.
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evidence of pervasive billing fraud at trial. Car-accident victims were referred to
PICC for treatment. Rather than basing diagnoses and treatments on the injuries of
each patient, the doctors at PICC gave predetermined diagnoses and treatments that
nearly exhausted the patients’ $10,000 in PIP benefits. 1 After trial,2 a jury found
that PICC’s conduct amounted to fraud and found PICC was liable for damages for
the fraudulent claims submitted. The jury also found State Farm was entitled to a
declaration it was not liable for any unpaid claims from treatment at PICC.
B. Intervenors’ Claims Against State Farm
Intervenors were policy holders with State Farm that suffered injuries from
car accidents in 2006. They received post-accident treatment at PICC and, as
insureds commonly do, assigned their rights to receive PIP benefits to PICC in
exchange for treatment. State Farm made initial payments, but the payments
ceased once State Farm filed suit challenging PICC’s fraudulent bills.
After it filed suit against PICC, State Farm sent letters to its insureds that
had received treatment at PICC. The letters sent to Intervenors stated State Farm
would “accept[] responsibility . . . for liability ultimately determined to be ow[ed]
for [PICC’s] services provided to [Intervenors].” The letters further requested that
Intervenors not assume more liabilities by receiving further treatment at PICC.
1
Under the Florida Motor Vehicle No-Fault Law (“No Fault Law”), Fla. Stat. §§
627.730–627.7405, car-accident victims that have purchased the mandatory PIP coverage have
$10,000 in coverage for personal injuries resulting from car accidents. Fla. Stat. § 627.736(1).
2
There were two trials; the first resulted in a mistrial.
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Shortly after receiving the letters indemnifying them for PICC’s claims,
Intervenors each revoked their assignment of PIP benefits to PICC. The
Intervenors also moved to intervene in the case against PICC to assert breach-of-
contract counterclaims against State Farm for its improper withdrawal of their PIP
benefits. The district court granted the motions. At trial, the jury found State Farm
was not liable for the unpaid claims accrued by Intervenors.
C. Resolution of the First Appeal
In the first appeal, we affirmed the judgment of the district court with the
exception of Intervenors’ breach-of-contract counterclaims and the declaratory
judgment against them. PICC, 427 F. App’x at 725–26. We determined that
Intervenors were entitled to recover damages, because State Farm violated section
627.736(7)(a) of the Florida Statutes, when it withdrew payment to PICC without
first obtaining consent or an independent medical report showing that Intervenors
were not receiving appropriate treatment. Id. at 723–25. The case was remanded
for a computation of damages. Id. at 725. The district court awarded $15,741,
plus interest, in damages, based upon unpaid bills attributed to Intervenors, and
determined that $11,000 in attorneys’ fees was appropriate. This appeal followed.
II. DISCUSSION
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State Farm asks us to revisit our decision in the first appeal that they violated
subsection 7(a),3 when they withdrew payment to PICC without first obtaining a
proper medical report. State Farm also argues (1) Intervenors lack standing, (2) the
computation of damages was erroneous, and (3) the damages awarded to
Intervenors should be offset from those awarded to State Farm from PICC.
Intervenors reply that the law-of-the-case doctrine prohibits reconsideration of the
issues raised by State Farm that previously were decided by this court. They cross-
appeal and seek at least $2.4 million in attorneys’ fees.
A. Law of the Case
We initially address the effect of our first decision on this appeal. State
Farm’s arguments that they did not violate subsection 7(a) and that Intervenors
lack standing both were decided previously and implicate the law-of-the-case
doctrine. Under the law-of-the-case doctrine, when a court decides an issue of law,
that decision is generally binding in subsequent proceedings. See Schiavo ex rel.
Schindler v. Schiavo, 403 F.3d 1289, 1291 (11th Cir. 2005). The doctrine applies
to issues decided both expressly and by necessary implication. Id. “The doctrine,
however, does not limit the court’s power to revisit previously decided issues when
(1) new and substantially different evidence emerges at a subsequent trial; (2)
controlling authority has been rendered that is contrary to the previous decision; or
3
“Subsection” refers to subdivisions of section 627.736 of the Florida Statutes.
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(3) the earlier ruling was clearly erroneous and would work a manifest injustice if
implemented.” Klay v. All Defendants, 389 F.3d 1191, 1197–98 (11th Cir. 2004).
Regarding State Farm’s assertion that Intervenors lack standing, State Farm
raised this argument in the first appeal. We decided otherwise by necessary
implication. 4 Because State Farm has not explained which, if any, of the
exceptions to the law of the case apply to this issue, we decline to revisit it.
We based our decision that State Farm violated subsection 7(a) primarily on
our reading of the report requirement of the statute. The decision also was based
on our interpretation that Florida law required mechanical compliance with the No-
Fault Law’s provisions for withdrawing payment, even when there is billing fraud.
See United Auto. Ins. Co. v. Viles, 726 So. 2d 320 (Fla. 3d Dist. Ct. App. 1998).
Since our previous opinion, a Florida appellate court has issued a decision that
places our ruling on this issue in doubt. Chiropractic One, Inc. v. State Farm Mut.
Auto., 92 So. 3d 871 (Fla. 5th Dist. Ct. App. 2012). As a federal court sitting in
diversity, the decisions of Florida’s District Courts of Appeal control our
4
State Farm argued that Intervenors did not have the right to seek their PIP benefits until
they revoked their assignment to PICC. True enough; Intervenors did not have a basis for
intervention until they revoked their assignment of benefits, but that does not control whether
they had standing to bring the claim. Because this is a diversity action, the question is whether
State Farm’s conduct threatened the rights of Intervenors as defined by Florida law. See Bochese
v. Town of Ponce Inlet, 405 F.3d 964, 981 (11th Cir. 2005) (explaining that whether there is a
legally enforceable right under state law sufficient to confer standing is determined by state law).
State Farm’s alleged breach of Intervenors’ insurance contract injured interests protected by state
law. See Allstate Ins. Co. v. Kaklamanos, 843 So. 2d 885, 896–97 (Fla. 2003) (recognizing an
insured may sue a defaulting insurer to force compliance with statutory mandates for PIP
benefits). As the district court noted, State Farm vehemently argued in state court that
Intervenors’ injuries under state law could be resolved as part of this case.
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application of Florida law, absent persuasive authority the Florida Supreme Court
would decide otherwise. Allstate Life Ins. Co. v. Miller, 424 F.3d 1113, 1116 (11th
Cir. 2005). This intervening change in controlling authority merits an exception to
the law-of-the-case doctrine. Consequently, we again must evaluate whether State
Farm was required to obtain a medical report prior to withholding payment for
PICC’s fraudulent claims.
B. Application of Subsection 7(a)’s Report Requirement
We review the denial of a motion for judgment as a matter of law de novo
and apply the same standard as the district court. Chaney v. City of Orlando, 483
F.3d 1221, 1227 (11th Cir. 2007). The interpretation of a statutory provision is a
purely legal issue that is resolved by the court. Cox Enters., Inc. v. Pension Benefit
Guar. Corp., 666 F.3d 697, 701 (11th Cir. 2012).
Florida’s No-Fault Law places certain restrictions on both the claims process
and on the ability of insurers to refuse to pay benefits. This appeal turns on the
distinction between the insurer’s ability to deny benefits and its ability to withdraw
benefits. In a usual case, the essential difference between a withdrawal of benefits
and denial of benefits is that, in a withdrawal, the insurer first has made a payment
but refused to make more payments. State Farm Mut. Auto. Ins. Co. v. Hyma Med.
Ctr., Inc., 22 So. 3d 699, 701 (Fla. 3d Dist. Ct. App. 2009); see also United Auto.
Ins. Co. v. Santa Fe Med. Ctr., 21 So. 3d 60, 65 (Fla. 3d Dist. Ct. App. 2009) (en
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banc); State Farm Mut. Auto. Ins. Co. v. Rhodes & Anderson, D.C., P.A., 18 So. 3d
1059, 1063–64 (Fla. 2d Dist. Ct. App. 2008). And, an outright denial would
involve no payment before the refusal. Hyma Med. Ctr., 22 So. 3d at 700.
The withdrawal of PIP benefits is governed by subsection 7(a). Subsection
7(a) provides:
(7) MENTAL AND PHYSICAL EXAMINATION OF
INJURED PERSON; REPORTS.
(a) Whenever the mental or physical condition of an injured
person covered by personal injury protection is material to any claim
that has been or may be made for past or future personal injury
protection insurance benefits, such person shall, upon the request of
an insurer, submit to mental or physical examination by a physician or
physicians. . . . An insurer may not withdraw payment of a treating
physician without the consent of the injured person covered by the
personal injury protection, unless the insurer first obtains a valid
report by a Florida physician . . . stating that treatment was not
reasonable, related, or necessary.
Fla. Stat. § 627.736(7)(a) (emphasis added). In short, usually before an insurer
may withdraw PIP benefits, it must obtain a valid report by a licensed physician
indicating the treatment was not reasonable, related, or necessary.
The denial of benefits, however, implicates subsection 4(b). Subsection 4(b)
requires insurers to pay valid claims within 30 days or face a penalty. An insurer
may elect to deny a claim under subsection 4(b), when it has “reasonable proof to
establish that the insurer is not responsible for the payment.” Id. § 627.736(4)(b)4
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(2006).5 Moreover, regardless of whether an insurer initially denies a claim under
subsection 4(b), it may still assert the claim was made in violation of subsection
5(b). See id. § 627.736(4)(b)6. In relevant part, subsection 5(b) provides that “[a]n
insurer or insured is not required to pay a claim or charges . . . [t]o any person who
knowingly submits a false or misleading statement relating to the claim or
charges.” Id. § 627.736(5)(b)1.c. Because the denial of benefits under subsection
5(b) does not implicate subsection 7(a), an insurer is not required to obtain a report
before refusing to pay benefits.
Viles involved a PIP claim, where the insurance company refused to pay
chiropractic bills for the insured on the grounds that the “bills were fraudulent and
not reasonably related to the accident in question.” 726 So. 2d at 320. The insurer
initially had paid some of the bills before withdrawing PIP benefits. The insured
sued for $3,632, the entirety of the unpaid bills, but a jury found the insured “had
sustained reasonable and necessary medical bills of only $2,000.” Id. at 321. The
appellate court held that a subsection 7(a) medical report is a “statutory condition
precedent” to the withdrawal of PIP benefits. Id. Because the insurer had not
obtained the report before withdrawing benefits, the court concluded it was barred
from asserting the bills were not reasonable or necessary. Id. Therefore, the
insurer was liable for the entire amount of the unpaid bills. Id.
5
A 2012 amendment struck “to establish” but left the provision substantively intact. See
2012 Fla. Laws Ch. 2012-197.
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We originally interpreted Viles to mean that, if an insurer pays a portion of a
claim, then it is required to obtain a report to discontinue payment. PICC, 427 F.
App’x at 724–25. While Viles was the only relevant decision that dealt with fraud,
it did not distinguish between withdrawals, when the claims were not reasonable or
necessary, and those caused by the fraud of the claimant. We reluctantly
determined that an insurer is required to comply with the statutory requirement to
obtain a report, even where a care provider knowingly submitted fraudulent claims.
Id.
After our decision, a Florida appellate court issued a new opinion that
addressed fraudulent claims submitted by a care provider. Chiropractic One, Inc.
v. State Farm Mut. Auto., 92 So. 3d 871 (Fla. 5th Dist. Ct. App. 2012).
Chiropractic One involved the submission of admittedly fraudulent claims by a
provider to the insurer. Id. at 873. The insurer had denied the claims for fraud.
The provider argued subsection 4(b) required that the insurer investigate each
claim and provide comprehensive written explanations for the denial of each claim
submitted by the provider, even where the provider was engaged in pervasive
billing fraud. Id. The court rejected that argument. It concluded subsection
5(b)1.c relieves both insurers and insureds from paying fraudulent charges and
claims submitted by providers. Id. at 874. Moreover, fraud in a single charge was
sufficient to poison the “entire ‘claim,’ i.e., the collective of all charges.” Id.10
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Subsection 5(b)1.c was enacted by the Florida Legislature in a 2003 revision
of the No-Fault Law, which is long after Viles. Florida Motor Vehicle Insurance
Affordability Act, 2003 Fla. Laws Ch. 2003-411. The “plain language of
[subsection 5(b)1.c] supports the invalidation of . . . claims” accompanied by
knowingly false or misleading statements. Chiropractic One, 92 So. 3d at 874. As
the Chiropractic One court stated:
The [2003] revision of the PIP statute had as a goal, among other
things, the curtailment of the perceived fraud in the PIP billing of
medical services. It is perfectly consistent with that goal for the
Legislature to intend to invalidate a billed claim if there is any
knowing submission of false or misleading statements relating to the
claim or charges submitted by a provider. We conclude, therefore,
that section 627.736(5)(b)1.c. should be interpreted in that fashion.
Id. at 875.
Given the decision in Chiropractic One, we conclude that, to the extent Viles
places obligations on insurers confronted with billing fraud, it is inapplicable.
Viles predated the relevant 2003 amendment to the No-Fault Law and other
continuing attempts by the Florida Legislature to deal with widespread billing
fraud. Moreover, there was no discussion in Viles of how fraud specifically affects
the statutory obligations imposed on insurers. It also did not deal with the practical
differences in claims submitted by providers rather than insureds. While it appears
that Viles is still good law in run-of-the-mill withdrawal cases, it has no application
in those involving complex and pervasive billing fraud.
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We interpret Chiropractic One to stand for the proposition that insurers need
not mechanically adhere to subsection 4(b)’s investigative requirement, when
knowing billing fraud is involved. Similarly, rote compliance with subsection
7(a)’s requirement to obtain a report before terminating all PIP benefits is
unnecessary, when an insurer seeks only to deny all claims coming from a
fraudulent provider.
We are unconvinced this appeal actually embodies a traditional withdrawal
case. While State Farm did make initial payments for Intervenors’ claims, those
payments were induced by PICC’s knowingly fraudulent submissions. As the
Chiropractic One court explained, knowingly fraudulent PIP claims are invalidated
under Subsection 5(b)1.c. Id. at 874–75. The initial payments therefore were
ineffective, making this a case of denied PIP benefits. Denial cases are governed
by subsection 4(b) and do not require a report as do withdrawals under subsection
7(a). State Farm was required only to have “reasonable proof” they were not
responsible for the payment, because obligations imposed by other parts of
subsection 4(b) are vitiated by the fraud. See id. at 873–74.
Moreover, once PICC fraudulently submitted Intervenors’ claims, they were
invalidated. Because fraud invalidated the submitted claims, the subsequent
revocation of the assignment of PIP benefits by Intervenors provided them with the
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hollow right to pursue claims that were no longer payable. The revocation did not
eliminate the fraud infesting and invalidating the claims.
Finally, it makes little sense that an insurer would be required to obtain an
individualized medical assessment for each claim, when the denial is based on
wholesale billing fraud by the provider. The blanket denial of claims coming from
a fraudulent care provider is markedly different from a withdrawal of benefits from
a single insured. Intervenors still could have sought treatment with other providers
and, because State Farm indemnified them from potential claims from PICC of
unpaid bills, they suffered no ill effect from the denial.
III. CONCLUSION
This case involves wholesale, knowing, and systematic billing fraud by care
providers. In general, Florida’s No-Fault Law imposes substantial procedural
safeguards to protect insureds and the system as a whole. But once PICC
submitted fraudulent claims to State Farm, the claims were invalidated and
unpayable. Intervenors’ eleventh-hour revocations of the assigned PIP benefits do
not now render them payable. Accordingly, we reverse our previous grant of
judgment as a matter of law, reinstate the jury verdict in its entirety, and,
consequently, vacate the awards of damages and attorneys’ fees for Intervenors.6
6
Given the disposition in favor of State Farm, we need not address the issues raised in
Intervenors’ cross-appeal.
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The matter is remanded with instructions to enter judgment in favor of State Farm
as to all claims.
REVERSED in part, VACATED in part, and REMANDED with
instructions.
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