Florida’s version of American Transit Ins. Co., United Auto Ins. Co, disclaimed benefits on the basis of a purported material misrepresentation that was made on the insurance application. United later realized there was no material misrepresentation and they were mistaken.
Medical provider sends bills United Auto Ins. Co well after the 35-day period under FSA 627.736(5)(c) to submit the bills. United Auto denies on this ground.
Provider brings a lawsuit stating that the insurance carrier is “equittably esopped” from disclaiming coverage based upon the prior disclaimer.
Presuit demand was made; the carrier did not pay. A lawsuit was commenced in Miami-Dade County Court. The parties agreed that necessity, relatedness and reasonableness were not issues. The parties made dueling summary judgment motions. The County Court sustained the defense of equittable estoppel
United appealed and the 3d DCA affirned in a written opinion.
“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 United Auto was properly estopped from denying coverage based on its own
Assume a medical necessity denial (they come in few and far between) or an EUO no-show denial (those are frequent). Can I still argue equitable estoppel? I called this “Domotor light” because I do not know the answer. Instead of a broad based legal pronouncement, I get a fact based nuanced decision. Florida courts are good like this. They hate deciding broad issues. First, you generally have either the PCA or summary reversal. Assuming you can get past that, the written decisions are quixiotic. And things are “better” now that the County Court orders go to the DCA as opposed to the “Circuit Court Appellate Division” where the orders were usually not even reported.