Florida has minimum requirements for both bodily injury liability and property damage liability ($10,000 to one person). Moreover, the Florida No-Fault law requires owners of motor vehicles to carry $10,000 of Personal Injury Protection (PIP) and $10,000 of Property damage liability (First-Party Coverage). Under Florida Statutes Section 627.736, PIP insurance must pay 80% of all reasonable and medically necessary medical treatment/services, plus lost wages, and funeral expenses, subject to certain defenses and provisions. Drivers also have the option of purchasing additional property damage insurance. In Florida, additional PIP coverage may also be purchased, said coverage is commonly referred to as “extended PIP.”
In a perfect world, all insurance policies would be written in clear and concise language, to identify the key provisions of the policy. However, many insurance policies are vague, ambiguous, and contain contradictory statements regarding the coverage at hand. The First District Court of Appeals recently ruled on an ambiguous policy in favor of the insured because the language wasn’t clear and didn’t specify what coverage was extended to the driver.
To give you a quick background of this case, Ms. Spaid sustained injuries in a car accident on February 3, 2011. She received medical treatment for the car accident that totaled an amount greater than $10,000. The sought medical treatment surpassed the $10,000 limitation in PIP insurance coverage, and as such, her automobile insurance carrier refused payment
Ms. Spaid demanded that her automobile insurance carrier, Integrity (Integon) Indemnity Corporation, pay all of her medical expenses, pursuant to the provisions contained in the Extended PIP section of her automobile policy. Ms. Spaid sought a declaratory judgment that the policy required her automobile insurer to pay all of her medical expenses related to the accident without a limit of $10,000 PIP. Integon declined to pay more than the $10,000 in medical bills because they felt as if that amount was the “threshold” or the limit of liability for PIP/extended PIP coverage. Both Ms. Spaid and her insurer moved for summary judgment. The question for the court to answer was whether or Not there was a $10,000 limitation for extended PIP coverage.
Ms. Spaid argued that the extended PIP endorsement/declarations pages of the policy did not reference or mention a limitation of liability ($10,000) regarding medical expenses/bills.She argued that the policy was ambiguous and that the ambiguity had to be decided in her favor, as it had to be construed against the insurance company. Her interpretation of the extended PIP provision was medical expenses paid at 100% with no limitation as to the amount paid.
The defendant argued that extended PIP endorsement does not modify the limitation of $10,000 for PIP to cover medical expenses/treatment, lost wages, funeral expenses, etc.
The court ruled in the defendant’s favor. The trial court agreed that the extended PIP endorsement didn’t modify or change the $10,000 PIP limitation of liability contained the basic PIP provisions.
District Court Ruling of This Case Explained
The District Court of Appeals, looked at Part A of the policy (limit of liability language), the Florida PIP Provision (Endorsement 1823) and the Extended PIP coverage addendum (Endorsement 4494). Importantly, the court noted that under the extended PIP provision, the “percentage of medical expenses covered are increased to 100%. The Extended PIP provision did not limit medical expenses/treatment/services to 80% of reasonable and necessary medical expenses, 100% coverage was offered.
Ultimately, the court held that the extended PIP endorsement created ambiguity. The ambiguity was based on the number of medical expenses that were recoverable under the policy. The insurance company argued that Ms. Spaid could have recovered 100% of medical expenses until $10,000 of extended PIP is reached. However, the District Court did not see it the insurers’ way. The District Court stated that the endorsement was vague and ambiguous in that the extended PIP endorsement could be subject to a different interpretation. The Court stated that, 100% of medical expenses could be recovered, pursuant to the policy, without the $10,000 PIP limitation. The insurance provider failed to express their intentions “clearly and unambiguously.” There wasn’t policy language indicating an intention to limit the amount of Extended PIP, nor was there a causal link between the PIP coverage section and the extended PIP coverage endorsement/provisions.
The District Court ruled in favor of Ms. Spaid and declared that 100% of her medical expenses were recoverable under the terms of her extended PIP policy.
What This Case Means to You
It is essential to contact an experienced PIP litigation attorney, in the aftermath of a motor vehicle accident. You may be entitled to greater coverage under your insurance policy than the insurance company is willing to provide. Most insurance carriers deny provisions in an insurance policy because they believe that their interpretation of the policy is correct. Most of the time, they leave much to be desired, in terms of the actual language of the policy. Ambiguous language in an insurance contract/policy is not acceptable and needs to be scrutinized by an experienced attorney. You may be missing out on key medical treatment that is actually contemplated by the terms of the policy.
General Information about Insurance Contracts
Insurance policies are unique in that the Courts of Florida are forced to look at the plain language/actual language of the contract. A court in Florida cannot “guess” as to what the insurance contract is attempting to convey. Insurance contracts are reviewed in favor of the person who purchases the policy, as the insurer writes the insurance policy and is basically bound by/stuck with what they write! The interpretation is strict, in that the insurer cannot argue a different interpretation of the policy after it is drafted; once again, they are stuck with the language of the policy “as written.”
Insurance contracts are strictly construed against the drafters of the policy. Most insurance contracts are confusing and ambiguous. Do not “give in” to the insurance carrier; contact a PIP attorney to read over the policy, decipher whether/not the contract is ambiguous, and draft a plan of action.