Assignment of Claim Only Works if Over Deductible
Post 4845
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In February 2019, Lauryn Frazier, a minor, was involved in a motor vehicle accident. Frazier was a dependent resident relative insured under a policy issued by USAA Casualty Insurance Company (“USAA”) which provided personal injury protection (“PIP”) benefits and medical payment coverage. Emergency Physicians, Inc. (“Emergency Physicians”) provided emergency services and care to Frazier as a result of the accident and charged $753 for its services. USAA applied the bill to the policy’s $1,000 deductible, indicating in an Explanation of Reimbursement form that the bill was subsumed by the deductible.
In USAA Casualty Insurance Company v. Emergency Physicians, Inc. d/b/a Emergency Resources Group, as assignee of Lauryn Frazier, No. 5D2023-0746, Florida Court of Appeals, Fifth District (July 26, 2024) resolved the dispute.
FACTS
Emergency Physicians, as assignee of Lauryn Frazier, sued USAA for PIP benefits. USAA admitted coverage for the accident but alleged that Emergency Physicians’ bill fell below the policy deductible and as such, was the full and complete responsibility of the insured/claimant.
Emergency Physicians asserted that USAA’s declaration page cannot be relied upon as evidence that Adams elected a deductible, and thus, because the deductible form was not executed, there was no evidence of a knowing $1,000 deductible election. The court was required to determine whether USAA properly reduced its payment of PIP benefits by imposing the $1,000 deductible.
The trial court entered its order granting Emergency Physicians’ motion for summary judgment and denying USAA’s motion for summary judgment. The court found that pursuant to the statute, an insurer must offer the option of electing a PIP deductible to the named insured at the time the initial application is taken and prior to each annual renewal, and pursuant to deposition testimony, the deductible form was not provided to the named insured prior to the policy renewing. Therefore, the court concluded, USAA did not comply with the statute.
ANALYSIS
In its motion for rehearing, USAA argued that deposition and affidavit testimony and the insurance contract were more than sufficient evidence to support its assertion that a deductible applied in this case and that Emergency Physicians provided no evidence to contradict the sworn testimony attesting to the accuracy and authenticity of the applicable insurance contract.
The Court of Appeals agreed with USAA that the trial court’s findings are contrary to the record evidence. USAA employees testified that the declarations page reflected Adams’ choices.
USAA testified that it sent the policy issue packet, which included the deductible form, when Adams first purchased her policy and a similar renewal packet was sent at every renewal period. Accordingly, the trial court’s findings were not supported by the record.
The affidavits and deposition testimony were sufficient to show that Adams elected a deductible. Moreover, the declaration page, which the trial court previously found to be part of the policy, clearly indicates that a PIP deductible applied.
Accordingly, because USAA provided sufficient evidence that Adams elected a deductible and because a deductible form is not required, the trial court erred in granting Emergency Physicians’ motion for summary judgment. Moreover, because Emergency Physicians did not contradict USAA’s deposition and affidavit testimony, there are no genuine issues of material fact.
The Court of Appeals reversed the order granting Emergency Physicians’ motion for summary judgment and remanded the case for entry of final summary judgment in favor of USAA.
ZALMA OPINION
This case went through motions for summary judgment and an appeal over less than $1,000, the amount of the deductible chosen by the insured when the policy was acquired. Clearly both parties expended more money on lawyers and court time than the amount in dispute. USAA established that the insured selected a deductible and was, therefore, personally responsible for the first $1,000 of medical bills. Since the bill was less than the deductible USAA had no obligation to pay. Neither side won.
(c) 2024 Barry Zalma & ClaimSchool, Inc.
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Anti-Public Adjuster Clause Is Effective in New York
Post number 5301
Read the full article at https://www.linkedin.com/pulse/public-adjusters-attempt-represent-insured-subject-zalma-esq-cfe-rubfc, see the video at and at and at https://zalma.com/blog plus more than 5300 posts.
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FACTS
NJPA is a New Jersey-based public adjusting firm licensed in New York. The dispute centers on ...
Anti-Public Adjuster Clause Is Effective in New York
Post number 5301
Read the full article at https://www.linkedin.com/pulse/public-adjusters-attempt-represent-insured-subject-zalma-esq-cfe-rubfc, see the video at and at and at https://zalma.com/blog plus more than 5300 posts.
Insurers May Contractually Prevent an Insured from Hiring a Public Adjuster
In Peter Barbato & North Jersey Public Adjusters Inc. v. Interstate Fire & Casualty Company, et al, No. 25-cv-5312 (JGK), United States District Court, S.D. New York (December 15, 2025) the plaintiffs, Peter Barbato and North Jersey Public Adjusters, Inc. (“NJPA”), filed suit against several insurance companies, including Interstate Fire & Casualty Company, Independent Specialty Insurance Company, and certain Underwriters at Lloyd’s of London.
FACTS
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Principles of Contract Interpretation Compels Reading Contract as Written
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In Eastside Floor Supplies, Ltd. v. SCS Agency, Inc., Hanover Insurance Company, et al., No. 2024-01501, Index No. 609883/19, 2026 NY Slip Op 01488, Supreme Court of New York, Second Department (March 18, 2026)
In May 2019, a fire damaged business personal property belonging to the plaintiffs, which was stored in portable storage containers at their Manhattan premises. At the time of the fire, the plaintiffs were insured under a businessowners insurance policy (BOP) issued by the defendant Hanover Insurance Company which provided general coverage for business personal property, and which included a specific extension for “Business Personal Property Temporarily in Portable Storage Units” (the portable storage ...
ERISA Saves Fraudulent Claims Suit
Post number 5306
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Allegations of Fraudulent Insurance Billing Must be Pleaded with Specificity
In Genesis Laboratory Management LLC v. United Healthcare Services, Inc. and Oxford Health Plans, Inc., No. 21cv12057 (EP) (JSA), United States District Court, D. New Jersey (March 13, 2026) Genesis Laboratory Management LLC (“Genesis”), a New Jersey-based molecular diagnostic and anatomic pathology laboratory, provided COVID-19 related testing services and submitted claims for reimbursement as an out-of-network provider to United Healthcare Services, Inc. (“United”) and Oxford Health Insurance, Inc. (“Oxford”). Metropolitan Healthcare Billing, LLC (“Metropolitan”), owned by the same individual as Genesis, handled the billing for Genesis.
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ERISA Saves Fraudulent Claims Suit
Post number 5306
Read the full article at https://www.linkedin.com/pulse/failure-provide-well-pled-facts-defeats-most-action-zalma-esq-cfe-b4zuc and at https://zalma.com/blog plus more than 5300 posts.
Allegations of Fraudulent Insurance Billing Must be Pleaded with Specificity
In Genesis Laboratory Management LLC v. United Healthcare Services, Inc. and Oxford Health Plans, Inc., No. 21cv12057 (EP) (JSA), United States District Court, D. New Jersey (March 13, 2026) Genesis Laboratory Management LLC (“Genesis”), a New Jersey-based molecular diagnostic and anatomic pathology laboratory, provided COVID-19 related testing services and submitted claims for reimbursement as an out-of-network provider to United Healthcare Services, Inc. (“United”) and Oxford Health Insurance, Inc. (“Oxford”). Metropolitan Healthcare Billing, LLC (“Metropolitan”), owned by the same individual as Genesis, handled the billing for Genesis.
FACTUAL BACKGROUND
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