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State Farm Fire & Casualty Company v. Silver Star Health and Rehab Inc.

December 19, 2011



This cause comes before the Court without oral argument on three motions for summary judgment: (Doc. 124) filed by Defendant Silver Star Health and Rehab, Inc. ("Silver Star"); (Doc. 125) filed by Defendant Judith McKenzie ("McKenzie"); and (Doc. 126) filed by Defendant Jean Colin ("Colin"). Plaintiff, State Farm Fire & Casualty Co. ("State Farm") filed three responses (Docs. 148, 149, 150); Defendants Silver Star and McKenzie replied (Docs. 155 and 156).

I. Background

Plaintiff sues Silver Star, McKenzie, and Colin (collectively the "Defendants") for submission of illegal and fraudulent claims for No-Fault Personal Injury Protection ("PIP") benefits and Medical Payment Coverage ("MPC"). In material part, the Complaint (Doc. 1) alleges that McKenzie, a licensed chiropractic physician, is held out to be the "owner" of Silver Star, a massage establishment. However, Plaintiff alleges that McKenzie "owns" Silver Star in name only and it is Colin who established and operates Silver Star, despite the fact that he is not a licensed health-care practitioner or relative of McKenzie. Thus, Plaintiff alleges that Colin is really the "de facto" owner of Silver Star and, as a result, Silver Star is operating in violation of Florida law. Plaintiff further alleges that Defendants contrived McKenzie's ownership of Silver Star solely for the purpose of avoiding Florida's statutory licensing requirement.

In 2004, the Florida Legislature enacted the Health Care Clinic Act ("HCCA") to strengthen the regulation of health care clinics throughout the state. In addition to expanding the types of businesses required to obtain licenses, it requires, inter alia, background checks for all owners, clinic inspection and certifications, proof of financial responsibility, and substantially higher fees to obtain licensure. This case however, turns on an exception to these requirements in FLA. STAT. §

400.9905(4)(g). It states, in relevant part, the licensure requirements of this part do not apply to . . . A sole proprietorship, group practice, partnership, or corporation that provides heath care services by licensed health care practitioners . . . which are wholly owned by one or more licensed health care practitioners . . . so long as one of the owners who is a licensed heath care practitioner is supervising the business activities and is legally responsible for the entity's compliance with all federal and state laws. However, a health care practitioner may not supervise services beyond the scope of the practitioner's license, except that, for the purposes of this part, a clinic owned by a licensee in § 456.053(3)(b) that provides only services authorized pursuant to § 456.053(3)(b) may be supervised by a licensee specified in § 456.053(3)(b).

FLA. STAT. § 400.9905(4)(g). "[I]t is unlawful to provide services that require licensure . . . without first obtaining . . . a license." FLA. STAT. § 408.804. Additionally, Florida's Motor Vehicle No-Fault Law provides that, "[a]n insurer or insured is not required to pay a claim or charges . . . [f]or any service or treatment that was not lawful at the time rendered . . . ." FLA. STAT. § 627.736(5)(b)(1)(b). State Farm's claims in this case are based entirely on this requirement in Florida's statute.

According to the Complaint, Plaintiff paid PIP and MPC benefits to Silver Star totaling over $151,000.00 on behalf of its insureds. In addition, Silver Star has submitted unpaid claims totaling over $70,000.00. Plaintiff seeks damages for unjust enrichment (Count I) and declaratory relief (Count II).

II. Standard

A party is entitled to summary judgment when it can show that there is no genuine issue as to any material fact. FED. R. CIV. P. 56(c); Beal v. Paramount Pictures Corp., 20 F.3d 454, 458 (11th Cir. 1994). Which facts are material depends on the substantive law applicable to the case. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). The moving party bears the burden of showing that no genuine issue of material fact exists. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986); Clark v. Coats & Clark, Inc., 929 F.2d 604, 608 (11th Cir. 1991); Watson v. Adecco Employment Servs., Inc., 252 F. Supp. 2d 1347, 1351-52 (M.D. Fla. 2003). In determining whether the moving party has satisfied its burden, the court considers all inferences drawn from the underlying facts in a light most favorable to the party opposing the motion, and resolves all reasonable doubts against the moving party. Anderson, 477 U.S. at 255.

When a party moving for summary judgment points out an absence of evidence on a dispositive issue for which the non-moving party bears the burden of proof at trial, the non-moving party must "go beyond the pleadings and by [its] own affidavits, or by the depositions, answers to interrogatories, and admissions on file, designate specific facts showing that there is a genuine issue for trial." Celotex Corp., 477 U.S. at 324-25 (internal quotations and citations omitted). Thereafter, summary judgment is mandated against the non-moving party who fails to make a showing sufficient to establish a genuine issue of fact for trial. 322, 324-25; Watson, 252 F. Supp. 2d at 1352. The party opposing a motion for summary judgment must rely on more than conclusory statements or allegations unsupported by facts. Evers v. Gen. Motors Corp., 770 F.2d 984, 986 (11th Cir. 1985) ("conclusory allegations without specific supporting facts have no probative value") (citations omitted); Broadway v. City of Montgomery, Ala., 530 F.2d 657, 660 (5th Cir. 1976).

III. Analysis

Defendants' arguments in the three motions for summary judgment are largely duplicative and overlapping; as such, the Court will treat them as one unless otherwise noted.

A. FLA.STAT. § 627.736

Florida's Motor Vehicle No-Fault Law, FLA. STAT. § 627.736, requires insurers to provide PIP benefits up to $10,000 for injuries resulting from motor vehicle accidents. See State Farm Mut. Auto. Ins. Co. v. Physicians Injury Care Center, Inc., 427 Fed. App'x 714, 717 (11th Cir. 2011). Insurers are not required, however, to reimburse for services and care that are "not lawful at the time rendered." FLA. STAT. § 627.736(5)(b)(1)(b).

Defendants move for summary judgment on both Counts based on FLA. STAT. §

627.736(1)(a). Under Defendants' reading of the statute, even if Silver Star was not properly licensed, State Farm is still required to pay the claims in this case because the services were lawfully rendered by a licensed physician. Defendants' rely on FLA. STAT. § 627.736(1)(a) which provides, ". . . medical benefits shall provide reimbursement only for such services and care that are lawfully provided, supervised, ordered, or prescribed by a [licensed] physician . . . ." FLA. STAT. § 627.736(1)(a) (emphasis added). Of particular importance to Defendants is the "disjunctive" wording of ...

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