5th District Court of Appeal Rules on Deductibles

Today, the 5th District Court of Appeal ruled on an issue concerning deductibles. The subject under question involved whether or not the insurer applies the deductible to the total amount charged, or whether the insurer gets to reduce the bills pursuant to the fee schedule, then apply the fee schedule. The court ruled in favor of doctors on this issue, rather than insurance companies.

For example, consider these two scenarios. In Scenario 1, someone is charged $5,000. Subtract the deductible of $1,000, which leaves $4,000 remaining. The fee schedule should then be applied, which knocks the amount allowed down to $3,000. The remaining bills are paid at about $2,400.

In Scenario 2, there is a $5,000 charge. The fee schedule is applied, which knocks the amount down to $3,000. The deductible is subtracted, leaving $2,000 remaining. The remaining bills are paid at about $1,600.

Scenario 1

$5,000 – Deductible = $4,000 + Fee Schedule = $3,000

Paid out at $2,400

Scenario 2

$5000 – Fee Schedule = $3,000 – Deductible = $2,000

Paid out at $1,600

If both scenarios are compared, the medical providers are paid better under Scenario 1. This ruling came out of Progressive vs. Florida Hospital Medical Center. You can see more about the opinion here. Likewise, there is a similar case on appeal in the 4th District Court of Appeal. Care Wellness Center, LLC, (A/A/O Virginia Bardon-Diaz) vs. State Farm Mutual Automobile Insurance Company is scheduled to have oral arguments on January 9, 2018, which means the court won’t issue an opinion until mid-2018. You can read more about the 4th District Court on their case docket here.

If you are an existing client, we have already been filing lawsuits on this particular issue for the last couple of years. Let us address your questions and concerns. Call our skilled Boca Raton injury attorneys as soon as possible. The Ovadia Law Group is here to help you navigate the legal process and do our best to help you meet your goals.

Contact us at (561) 513-5519 or fill out our online form to schedule a free case consultation with us today.


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