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Every insurance policy issued in Florida contains the requirement, in some form or another, that the insurance company be put on notice of the claim and certain other claim events. Failure to provide notice in accordance with the policy’s terms may allow the insurance carrier to deny the claim.

Florida law is quite clear that notice to one’s agent or apparent agent is notice to the principal. That is true in the context of insurance. See Johnson v. Life Insurance Company of Ga., 52 So.2d 813, 815 (Fla. 1951). Insurance brokers, on the other hand, are not agents. Therefore, notice to brokers is typically not imputed to the principal.

In Gay v. Association Cas. Ins. Co., So.3d , 38 FLWD74 (Fla. 5th DCA 12-28-2012) (on rehearing) the insured maintained an insurance policy with Association Casualty Insurance Company for uninsured and inderinsured motorist coverage which was purchased through Burkey Risk Services, Inc. The insurance policy contained notice instructions. Following a serious motor vehicle accident, Gay informed Burkey of the accident and claims to have received permission from Burkey to cash a check issued by GEICO, the tortfeasor’s carrier, in partial payment of his damages. When Gay sought underinsured coverage through his policy, Association denied the claim, citing a breach of the policy’s notice provisions.
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While personal injury litigation in Florida courts is not supposed to be a game of “gotcha,” or trial by ambush, Surf Drugs, Inc. v. Vermette, 236 So.108, 111 Fla.1970,” unless attorneys pay careful attention, it can happen in their cases. One of the ripest areas for this gamesmanship to occur is in the use of accident videotape.

Premise liability defendants often have videotape of the accident. Rarely is it produced presuit, even when doing so might head off a lawsuit. Proof that tried and true policies aren’t always the best. Even during suit, defendants resist turning over the tape. In the hope of catching Plaintiffs giving testimony inconsistent with the events captured on tape, even if the inconsistencies are based on a lack of clear memory or a lack of knowledge, rather than untruthfulness, they want to question plaintiffs before producing the accident footage.
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Plaintiffs personal injury lawyers typically have preferences in which medical providers they use to treat and render expert opinions on such issues as causation, disability, and prognosis. This is often due to familiarity and confidence in the provider’s competence. It is sometimes dictated by financial considerations.

Many people are uninsured or have inadequate coverage. When care is required that exceeds a person’s current ability to pay, many medical providers refuse to accept those people as patients. Some providers, however, are willing to take on the care and treatment of individuals in this predicament with the expectation of receiving payment from the personal injury case. To insure payment upon the favorable resolution of a case, these doctors sometimes require the patient and their personal injury lawyers to sign a letter of protection (LOP), an agreement to pay from the recovery.

This is not unreasonable. People with injuries require care. Most doctors cannot afford to work for nothing.
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scales of justice.jpgExpert testimony plays a major role in almost every civil and criminal legal case. In Florida state courts expert testimony is governed by sections 90.702-90.706, Florida Statutes. The goal of the statutes is to insure fairness and impartiality in the trial of cases. The standard for when expert testimony is allowed is set forth in

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dollars.jpgPayments made by health insurance and Medicare must be repaid by the beneficiary of the payments from money recovered in the personal injury case for which the medical care was furnished. (Note: PIP, which is no-fault insurance for medical bills in car accidents, does not have to be reimbursed.) In determing how much is owed, an end date beyond which further payments are not reimbursable must be established.

The cutoff date varies depending on the entity involved.

HEALTH INSURANCE: The cutoff date depends on whether the policy is subject to ERISA. If it is not, the lien ends at the date of settlement. See Florida’s collateral statute — 768.76. It is fairly well established (although not conclusively — see Coleman v. Blue Cross and Blue Shield of Alabama, Inc. So.3d , 35 FLW D2718 (Fla. 1st. DCA 12-8-2010) for a contrary view) that the collateral source statute does not apply to ERISA plans. Rather, those lien rights are controlled by the subrogation/reimbursement language in the Summary Plan Description (SPD). The SPD should be requested, but in all likelihood its provisions are expansive, allowing for recovery of all charges related to the accident. The plan may even provide that it is not responsible for covering post-settlement accident related care.
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law books.jpgBecause Florida workers’ compensation permanent total disability (PTD) benefits are paid at the rate of 66-2/3% of an injured worker’s average weekly wage (AWW), an employee qualifying for both PTD and Social Security Disability (SSD) benefits may be in line to receive combined payments in excess of his or her AWW. Is this allowed under Florida law? The answer is, it depends.

Florida Statute 440.15(9)(a) and 42 U.S.C. s. 424(a) address the issue. The federal law allows the combined payments to equal 80% of a person’s average current earnings (ACE). ACE is a calculation, based on one of three formulas, used by the United States Social Security Administration to determine monthly SSD payments. Payments in excess of the 80% are subject to an offset.

Who gets the offset, the federal government, against SSD, or the workers’ compensation insurance companies? Unless a state has laws allowing workers’ compensation carriers to take the offset, the offset belongs to the Social Security Administration. The SSA will reduce SSD payments to bring the combined benefits down to the 80% mark.
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legal document.jpgMost Florida insurance policies require the insured to give notice of a loss to the insurer within a prescribed period of time, typically 30-60 days. The reason for the requirement is to allow the insurer to investigate the claim while the facts are fresh. While late reporting is presumed to prejudice the insurer, the presumption may be rebutted by showing that the insurer has not been prejudiced by the late notice. See Bankers Ins. Co. v. Macias, 475 So.2d 1216 (Fla. 1985) (failure to cooperate is a condition subsequent and it is proper to place the burden of showing prejudice on the insurer) Kings Bay Condominium Association, Inc. v. Citizens Property Insurance Company, 4th District. Case No.4D11-4819. December 12, 2012 (the trier of fact was allowed to consider if the insurance company was prejudiced by a 29 month delay in filing the notice of claim); Bontempo v. State Farm Mut. Auto. Ins. Co., 604 So.2d 28 (Fla. 4th DCA 1992); Ramos v. Northwestern Mut. Ins. Co., 336 So.2d 71 (Fla. 1976) (an insurer may not avoid liability under its policy by merely showing the violation of a clause requiring “assistance and cooperation” of the insured without a further showing of how this violation prejudiced the insurer); American Fire & Cas. Co. v. Collura, 163 So.2d 784 (Fla. 2d DCA), cert. denied, 171 So.2d 389 (Fla. 1964); American Fire & Cas. Co. v. Vliet, 148 Fla. 568, 4 So.2d 862 (Fla. 1941); United States Fidelity & Guar. v. Snite, 106 Fla. 702, 143 So. 615 (Fla. 1932).

A presumption which can be overcome by competent evidence is known as a rebuttable presumption.
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greed.jpgFor Florida accident victims and those who care for and about them, the tyrannical reign of Jeb [Bush] the Horrible (Governor of Florida from 1999 to 2007) continues to haunt.

Once upon a time in Florida, employees hurt at work could sue their employers in tort by proving that an employer’s conduct created a “substantial certainty” the harmful accident would occur. Although the standard was tough, it still gave employees harmed through conduct exceeding mere negligence a fighting chance of being fairly and fully compensated, rather than being limited to the oftentimes inadequate benefits available under Florida’s workers’ compensation system. A victim making the requisite showing was able to overcome an employer’s workers’ compensation immunity.

Dear Jeb and his uncaring Republican lackeys in the Florida Legislature were dismayed that working men (and women) had a fighting chance against the beloved “Job Creators,” so they eliminated the right. In 2003, the Florida Legislature effectively overruled the Florida Supreme Court case of Turner v. PCR, Inc., 754 So. 2d 683 (Fla. 2000), the case which gave a decent interpretation to the “substantial certainty” standard, by amending Florida Statute 440.11 with the “virtually certain” standard. The pertinent language reads as follows:

The employer engaged in conduct that the employer knew, based on prior similar accidents or on explicit warnings specifically identifying a known danger, was virtually certain to result in injury or death to the employee, and the employee was not aware of the risk because the danger was not apparent and the employer deliberately concealed or misrepresented the danger so as to prevent the employee from exercising informed judgment about whether to perform the work.

See F.S. 440.11(1)(b)2.

As fairly stated by the 4th DCA in List Industries v. Dalien (opinion issued on January 23, 2013), “The change from ‘”substantial certainty”‘ to ‘”virtually certain”‘ is an extremely different and a manifestly more difficult standard to meet. It would mean that a plaintiff must show that a given danger will result in an accident every — or almost every — time.”
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people.jpgFlorida law has long recognized that a car is a dangerous instrumentality. (The dangerous instrumentality doctrine was adopted in Southern Cotton Oil Co. v. Anderson, 80 Fla. 441, 86 So. 629 (1920).) This is based on the simple fact that a car, in the wrong hands and used improperly, is likely to cause great damage. To discourage owners from being careless in the use of their vehicles by others, Florida law holds them responsible for the negligent acts of consensual drivers. This is known as vicarious liability, or liability without fault. (Owners can also be liable under a different legal theory known as negligent entrustment. See this blog for an explanation of the theory: Florida Motor Vehicle Owners Accountable for Damages Without Driving Negligently.)

With rare exception*, vicarious liability is determined through title ownership. This proposition gained solid footing in Metzel v. Robinson, 102 So.2d 385 (Fla.1958), which established the following legal standards: (1) as a matter of law, if a person causes or permits his name to be on the title when the vehicle is acquired, he cannot contradict the title by claiming that he did not intend to be an owner at the outset; (2) as a matter of law, once that person has caused his name to be affixed to the title, he must take some affirmative action to divest himself of that interest to avoid liability; and (3) as a matter of law, relinquishing possession of and having nothing to do with the vehicle after its acquisition is not sufficient to divest that person of his legal interest. (This summary of Metzel is laid out by the 5th DCA, in Bowen v. Taylor-Christensen, 98 So.3d 136, @ 142 (Fla. 5th DCA 2012), a must-read case.)
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maze2.jpgOur previous blog addressed the procedure for satisfying Medicaid’s lien from money received in Florida personal injury cases from liable third parties.The present blog will focus on satisfying Medicare’s lien from third party proceeds. The leading case on the issue is Hadden v. United States, 661 F.3d 298 (6th Cir. 2011).

Medicare and Medicaid are federal programs that provide medical insurance to various classes of individuals. Medicare is for qualified elderly and disabled persons, see 42 U.S.C., §§1395 et.seq., Medicaid is for individuals who cannot afford to pay their own medical costs. See 42 U.S.C. §§1396 et seq. Both programs aim to make themselves only secondary payers as to medical expenses for which some other entity (e.g., a tortfeasor) bears responsibility. Medicare — 42 U.S.C. § 1395y(b)(2), Medicaid — 42 U.S.C. §§ 1396a(a)(25)(A), (B), (H). Hence, the need for personal injury lawyers to know each programs’ lien laws.

In Hadden, Medicare paid more than $80,000 for medical care on behalf of Hadden for injuries he sustained in an accident. Hadden subsequently settled a personal injury claim with a tortfeasor for $125,000. After subtracting a portion of the attorneys’ fees that Hadden himself had paid to obtain the settlement, see 42 C.F.R. § 411.37, Medicare determined that Hadden owed it $62,338.07. Hadden argued that the case settled for 10% of its actual value, therefore, Medicare’s recovery should be limited to a proportional 10% of its outlay, or slightly more than $8,000. The 6th Circuit disagreed.

42 U.S.C. §1395y(b)(2)(B)(ii) provides:

A primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate Trust Fund for any payment made by the Secretary under this subchapter with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service. A primary plan’s responsibility for such payment may be demonstrated by a judgment, a payment conditioned upon the recipient’s compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary plan or the primary plan’s insured, or by other means.

The Court interpreted the word “responsibility” to mean the amount the recipient claimed was due from the tortfeasor, rather than a compromised amount he or she receives from the tortfeasor. In other words, the beneficiary’s obligation to reimburse Medicare is “defined by the scope of his own claim against the third party.” In the Court’s view, “a beneficiary cannot tell a third party that it is responsible for all of his medical expenses, on the one hand, and later tell Medicare that the same party was responsible for only 10% of them, on the other.”
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