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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The Professional Claims Handler
Post 5218
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-8-barry-zalma-esq-cfe-zdwsc, see the full video at https://rumble.com/v70zl4s-the-zalma-philosophy-of-claims-handling-part-8.html and at https://youtu.be/MIYcF71ffRQ, and at https://zalma.com/blog plus more than 5200 posts.
Claims Commandment X – Thou Shall Not Pretend to be a Lawyer
Some experienced and professional claims people know the law in their area of expertise better than most lawyers.
Adjusters should be adjusters and leave lawyering to lawyers. Similarly, lawyers should be lawyers and never try to be adjusters.
Claims Commandment XI – Thou Shall Empathize With the Claimant
Everyone presenting a claim is unhappy, disturbed, shocked, injured and needs help.
Empathy is identification with and understanding of another’s situation, feelings, and motives. It is the ability to understand another person’s circumstances, point of view, thoughts, and feelings....
HOW TO CREATE AN EXCELLENCE IN CLAIMS HANDLING PROGRAM
See the full video at https://rumble.com/v70wb2i-the-zalma-philosophy-of-claims-handling-part-6.html and at https://youtu.be/tL5nDKPEs40 and at https://zalma.com/blog plus more than 5200 posts.
Post 5217
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry.
An Excellence in Claims Handling program begins with a statement in the insurer’s claims manual or statement of professionalism that it is dedicated to providing excellence in claims handling to every insured who presents a claim.
The excellence in claims handling program should include, at a minimum:
A series of lectures supported by text materials explaining:
A definition of insurance.
How to read and understand an insurance policy.
How to interview an insured, witness, or claimant.
How to assist an insured in the insured’s obligation to ...
The Professional Claims Handler
Post 5216
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-5-barry-zalma-esq-cfe-jde8c, see the full video at https://rumble.com/v70q4x8-the-zalma-philosophy-of-claims-handling-part-5.html and at https://youtu.be/6b9tZQsEkB4, and at https://zalma.com/blog plus more than 5200 posts.
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry.
Standards to be a Professional Claims Adjuster
The Insurance claims professional should be a person who:
1. Can read and understand the insurance policies issued by the insurer.
2. Understands the promises made by the policy.
3. Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
4. Are competent investigators.
5. Have empathy and recognize the difference between empathy and sympathy.
6. ...
The Professional Claims Handler
Post 5219
Posted on October 31, 2025 by Barry Zalma
An Insurance claims professionals should be a person who:
Can read and understand the insurance policies issued by the insurer.
Understands the promises made by the policy.
Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
Are competent investigators.
Have empathy and recognize the difference between empathy and sympathy.
Understand medicine relating to traumatic injuries and are sufficiently versed in tort law to deal with lawyers as equals.
Understand how to repair damage to real and personal property and the value of the repairs or the property.
Understand how to negotiate a fair and reasonable settlement with the insured that is fair and reasonable to both the insured and the insurer.
How to Create Claims Professionals
To avoid fraudulent claims, claims of breach of contract, bad faith, punitive damages, unresolved losses, and to make a profit, insurers ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
