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Certification Fails In Challenge To Insurer’s Use Of Coding Initiative For PIP Reimbursement

April 12, 2012 9:17 AM | Posted by Morande, Dean | Print this page
In DWFII Corp. v. State Farm Mutual Auto. Ins. Co., No. 11-10162 (11th Cir. Mar. 27, 2012) (unpublished), the Eleventh Circuit upheld the district court’s denial of certification to a purported class of medical providers challenging State Farm’s use of National Correct Coding Initiative edits to determine reimbursement for Personal Injury Protection claims under Florida’s no fault insurance statute.

At the outset, typicality was lacking because, for each claim—even if a medical provider could show that an edit was improper under the statute—the medical provider would have to satisfy several other elements to demonstrate it was entitled to reimbursement of the disputed charge. (For example, for each claim, the medical provider would have to show the bill was properly completed under the statute, the benefits of the insurance plan were not exhausted, the recipient of the services had valid coverage with State Farm, and the medical provider actually performed the services for which it billed.) For these same reasons, the plaintiff was unable to show that the predominance requirement was satisfied.

The declaratory and injunctive relief class failed for the additional reason that the monetary damages sought by the medical providers were not incidental to the requested equitable relief.