UR Health Chiropractic Corp. v. Progressive Select Insurance Company
Filing
16
ORDER granting 10 Defendant's Motion to Dismiss. Closing Case. Signed by Judge Federico A. Moreno on 1/18/2018. (da00) NOTICE: If there are sealed documents in this case, they may be unsealed after 1 year or as directed by Court Order, unless they have been designated to be permanently sealed. See Local Rule 5.4 and Administrative Order 2014-69.
UNI
TED STATES DI
STRI COURT FOR THE
CT
SO U TH ERN DI
STRI OF FLO RI
CT
DA
M i m iDi s on
a
vi i
C as N um be 17e
r: 62086- V - O R EN O
Cl M
UR HEALTH CHI
ROPRACTI CORP. za o
C
, ll
Oxa Kouzme
na
nko, behafofis l a a1
on
l t ef nd 1
o he ssmia l st t
t r i lry iuaed,
Pl i if
a ntf ,
V S.
PROGRESSI SELECT I
VE
NSUM NCE
COM PAN Y,
Dee
f ndant
.
O R D ER G M NT I G D EFEN D AN T' M O TI N T O D I I
N
S
O
SM SS
Pl i if UR H e 1h Chiopr tc Cor aton br
a ntf
at
r ac i
por i
ought t s a ton a ns D e e
hi c i
gai t f ndan
t
Pr r s i Se e t l ur nc Com pa t c le
og e sve l c ns a e
ny o ha l nge is r i bur e e pr c i s r a e t
t e m s m nt a tce el t d o
p ro a ij r p o e to b neis Pr g e sv s bsq e tymo e t d s s tec mplitf r
es n l nu y r tcin e ft. o r sie u e u nl v d o imis h o an o
f iur t sa e a cli upon whih r i ca be gr t d.Fort r a ons dic s d be o ,i i
a l e o tt
am
c elef n
an e
he e s
s us e l w t s
ADJ
UDGED t tPr es i smoton t dim isi GRAN TED.
ha ogr sve'
i o s s s
The Part es
i
A. Rel
evantNon- v
part
1. Oxana Kouz enko
m
Ox n Ko z n o i a Flrd r sd n wh s san d ij re d rn a a t mo ie
a a u me k s o ia e ie t o u t ie nu is u ig n u o b l
ac i nt t t oc ur ed on A ug t 6, 201 A t t t tm e, Kouze e
c de ha c r
us
6.
ha i
m nko w a c r d unde a
s ove e
r n
i ur nc polc i s d by Def nda Pr es i Sel c I ur nc Com pa
ns a e
i y s ue
e nt ogr sve
e t ns a e
ny. The Polcy
i
p o ie Ko z n o wih p ro a ij r p oe to b n ft i a c r n e wih Flrd '
r vd d u me k t e s n l n u y rtcin e eis n c o da c t o ia s
M o orVe c eNo- ul La .lKouzm enko a sg d t be t unde t sPolc t UR Heat
t
hil
Fa t w
s i ne he neks
r hi i y o
lh
a d i e h n e UR He lhp o ie me ia sr c st hepte tKo z n ' ij re .
n ,n xc a g ,
at r vd d dc l evie o l r a u me ko s n u is
B. The Partes
i
2 Pli # - UR He Ih Chio a tcCopo a in
. ant
at r pr ci r r to
i s n owa d
UR He t i a Fl i c por ton wih is p i i pl e of busne s i Br r
a1h s
orda or a i
t t rncpal ac
Co ny Flrd .t o ie c r p a tcsr ie t h l p te t wihav reyo ij re .
u t, o ia Ipr vd s hio rci e vc s o ep ain s t a it f nu is
J De nd nt Pr g e sv See t n u a eCo n
. fe a - o r s ie lc I s r nc mpa y
Pr es i Seec l ur e Compa i a f ei com or ton t t pr des a ong
ogr sve l t ns anc
ny s or gn
a i ha ovi , m
ot rt ngs a o obiei ur ncei Fl rda Pr e sves d an a o obie i ur epolcyt
he hi , ut m l ns a
n o i . ogr s i ol
ut m l ns anc
i o
Ko
uzme
nko.Thi Polc wa i e f c a t tme ofKouz e s a om obie a ci nt whi
s iy s n fe t t he i
m nko' ut
l c de , ch
tig rd P o e sves o lg to t p o i e Ko z n wi t pes n lij r p o e to
rg ee r g si ' b iain o r v d u me ko t he ro a n u y r tcin
h
be isi ude i t polc
neft ncl d n he iy.
II. Backzround
Folwig t 2 6 a tmo ie a cd n , Ko z nk a sg d t pes n l ij r
l n he 01 u o bl c ie t u me o sine he ro a nu y
o
pr eci n be isfom he Pr es i a omobie i ur nc polc t UR He t l t ' UR
ot to neft r
r ogr sve ut
l ns a e iy o
alh. n ul
n,
He 1 p o ie c io r ci sr ie t hep Ko z n rc ve fo t ep ro a ij re s e
at r vd d hr p a tc e vc s o l u me ko e o r r m h es n l n u is h
h
s t i d durng t ac i nt Pr r s i s e nty r i btr e UR He t f c rai
usane
i he c de . og e sve ubs que l em zs d
a1h or e t n
me ca s r i e c r byt polc
di l e v c s ove ed he iy.
To c l ult t r i bur e nt owe t UR Heat unde Kouz e s i ur nce
a c a e he em s me
d o
1h
r
m nko' ns a
polc Pr r s i a id M e c r s M uli e Pr ed e Pa nt Reduci Rul t UR
iy, og e sve pple
di a e'
tpl oc ur
yme
ton
e o
H e t s bil f c r a tc s r i e . The M uli e Pr edur Pa e Red to Rul alh' ls or hi opr c i e v c s
tpl oc
e ym nt
uc i n
e
whi a cou s f r t s ngs a efi i nces a hi ve whe a pr de pe f m s m uli e
ch c nt o he avi
nd fc e i c e d
n
ovi r ror
tpl
m e ca pr edur s i a sngl da r duc pa e t a he lhc e pr de by a s t
di l oc
e n
i e y- e es ym nt o
a t ar ovi r
e
lUndert Fl i M ot Vehi e No- tLaw , a o bi o rt smus h vepe s na ij r
he orda
or
cl
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n h v n n u o bie c i n . e a Stt Se . 7.36 l()
pe c t e f s ond a s e ntpr dur spr de t t s
r en ag or ec
nd ubs que
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te
he a
Se 7 Fe Reg. 68,
e
d.
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ppl ng he
tpl oc ur
ym nt duc i
e,
Pr r sve de r as t mnountofr mbur e
og es i
c e ed he
ei
s mentdibur e t UR He t
s sd o
alh.
UR He 1 c n e e ta u d rFlrd ' p ro a ij r p oe to sau e a wela
at o c d s h t n e o ia s e s n l n u y rtci n ttt s l s
h
Ko e
uzm nko' a om obie i ur nc polc Pr r sve had t rght t utlze t M uli e
s ut
l ns a e
i y, og es i
he i
o ii he
tpl
Pr e ePa ntRe i Rul t c l ult r mbur e towe t UR Heat f pr di
oc dur yme
ducton e o a c a e ei
s men
do
1h or ovi ng
Ko z k wihp ro a ij r p oe to b n ft. He l as c n e e - or a la t d e
u me o t e s n l nu y r tcin e eis UR at lo o c d s - , t e s, o s
h
no chal - t tPr e sve a cur t y a i d t M uli e Pr ed e Pa e Re ton
t lenge ha ogr s i c ael pple he
tpl oc ur ym nt duc i
Rul t U R H e lh' bil .
eo
a t s ls
H ow e r UR Hea t co e
ve ,
lh nt nds t t Pr es i s il vi at d t 1 w by ar ta iy
ha ogr s ve tl ol e he a
bir r l
a yi t M uli e Pr e e Pa e Reduc i Rul t s e he t r pr vi r bu not
ppl ng he
tpl oc dur ym nt
ton e o om
alhca e o de s t
t o he s l a lge t tPr r s i di nota y t M uli e Pr edur Pa e Re ton
o t r . t le s ha og e sve d
ppl he
tpl oc e ym nt duc i
Rul t r duc r mbur e
e o e e ei
s ment a
mount owe t t ag tc i ng pr de s' UR He t
s
d o i nosi/magi
di
ovi r .
'
a1h
a gue t tby a yi t M uli e Pr e e Pa ntRe ton Rul ç o pr de s lke t
r s ha
ppl ng he
tpl oc dur yme
duc i
e k ovi r i he
t
Plitf ' a d ç r ta i c o l l NOT t a pl i t da n tci gn pr vd r,
an if n i bi rl h osi
a r y
ng
o p y t o ig osi/ma ig o ie s'
'
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ogesi nga d n awf t ci nat y onduct' ( p. a 2. Fi ly, e n i
di
. Res t ) nal ve f
'
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og es i
y ii e he
nt od ton
e or om l- ovi r ,
Heat c e t tt i ur epolc mus f o des fcintnotc t t i ur ofghil
lh ontnds ha he ns anc iy t ' vi ufi e
pr
ie o he ns eds t s
dici naor prctce. (d.
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Pr e sve m ant i t ti has no oblga i t e pl t Pa
ogr s i
i ans ha t
i ton o m oy he ymentRe ton Rul
duc i
e
u f ml f r a lpr de s ort notf i ur when i ap i t Pa
nior y o 1 ovi r , o iy ns eds
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duc i
e
no unionnl l not t tU R Hea t of e s no s
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uppor f is al- - hi r l or is no i
t or t lor not ng u e t tce
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r
111 St
. andard
t'o s v ve a m oto t di m i s pl i if m us do m or t n m er l s a e l gal
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l
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t
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oncusons' nse d ai if
'
t i eg ome s cii f c ualba i f t e c l i or
al
pe fc a t
ss or hos onc usons
fc dimis oft i cl ms' Jac s v.BelsouhTee
a e s sal her ai .' k on
l t lcomm. 37 F.d 1 1 (11hCi.
, 2 3 250, 263 t r
2004) W he r i on amoton t dimis ac tmus viw t c aiti t lgh mos
.
n ulng
i o s s, our t e he ompl n n he i t t
f vor bl t t pli if a a e t pl i ifs we lplade f c s a tue. Se St Josph'
a a e o he antf nd cc pt he antf
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s , n . . s r o , 9 2 4 , 5 1 t r 9 6 . s e e, o v r d e
nota y t l lc us ons Se As r .f v I b l 1 9 S. .1 37 1 4 ( 0 ) Mo e v r
ppl o ega oncl i . e hc o t . q a , 2
Ct 9 , 9 9 20 9 . r o e,
kwl ielg lc n l so sc n p o d t efa wo kofac mpan ,h ymu tb s p o tdb
i h l e a o cu in a rvie h r me r
l
o lit te s e u p re y
fcu lalg to s' I a 1 0. Th e'ta t a alg to smu tb e o g t riearg t o
a t a le ain . d t 95
'
os 'l cu l le ain s e n u h o as ih t
g
r if a
ele bove t s c a i lvelon t a s
he pe ul tve e
he s umpton t tal oft c
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ai ' le tons r
tu ' BelAt.Cor v Twombl 550 U. 544,545 (
r e. l l p. .
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y
S.
2007) l s t t compl ntmus no
. n hor, he
ai
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ey l
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t
t m nsr t ha he e der s ntted o elef e qbal
1 S.Ct a 1 0.
29
. t 95
l . Anal i
V
vss
Flrd ' pes na ij r p o e to sau e a d Ko z n o' a tmo ie i u a c
o ias ro l nu y r tcin ttt n
u me k s u o b l ns rn e
polc a horze Pr es i s us of t M uli e Pr e e Pa e Re ton Rul t
i y ut i
ogr s ve' e
he
tpl oc dur
ym nt duc i
e o
c c a e r i bur em e ow e t U R Hea l U nde Kouz e
al ul t e m s nt
d o
th.
r
m nko' polcy,Pr es i a ee t
s i
ogr s ve gr d o
d y be ist ta i ur d pe s i e il t r eve pur ua t t Fl i M ot Ve ce
t
pa neft ha n ns e r on s ntted o ec i
s nt o he orda
or hi l
No F ul La .. b c u eo b d l ij r '( s a 5. P o r si f te e plie t a te
- a t w . e a s f o iy nu yv Re p. t ) r g e sve urh r x an d h t h
'
ttl mo n o b n ft p i t l b s b e t oteCe trf rM e iaeS r ie c dn p lce
o a a u t f e eis ad s l e u j c t h ne o dc r e vc s o ig o iis
wi
a pa m e me hodol es' whih i ude t M uli e Pr dur Payme Reduci Rul
nd y nt t
ogi ,
' c ncl
he
tpl oce e
nt
ton e.
(d a 6. Fo iasp ro a ij r p o e to sau ep o d sa dto a s p o tb e p e sy
1 . t ) lrd ' e s n l nu y r tcin ttt r vie d iin l u p r y x r sl
r s r i i ur r 'rght t us She M edia ec ngpolc e a pay e me hodol i soft
e e vng ns e s i s o e t
t
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og e
he
f de alCe e s f M e ca e a M edi ai Se vi es ...t det r i t a opra e a ou of
e r
nt r or di r nd
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o e m ne he ppr i t m nt
ri sme tf medi ls r i s s is orc e....' a.SttAr j627. 54 3 .
embure n or ca e vce , upple , ar
'Fl a. m.
736()*()
UR Heat expl ns howe r t t dgl is i not whehe t Dee nt c n
lh
ai ,
ve , ha tthe sue s
t r he fnda a
ge rly ap y (he Muli e Pr edur Pa ntRe ton Rul ,'but û t r ( orda'
neal pl t
tpl oc e yme
duci
e)'
s he Fl i s
whe
p ro a ij r p oe to sau e alwsteDee d n t d srmi trl a pl ( e Mulpl
es n l n u y rtcin ttt) l
o h f n a t o ici nao iy p y t
h
t e
i
4
Pr c d r P y n Re u t n Rue . UR He 1 ag e t a Pr g e sv ma n tuiiet e
o e u e a me t d ci
o l)'
'
at r u s h t o rs ie y o tl h
h
z
Pay e Red tonRul f onl s e butnotal pr vi r
m nt uci
e or y om l- o de s:
The Pli ifaleg t ti t Defnda c est e oy (he
antf l es ha f he e nt hoos o mpl t
M utpe Pr c d r Pa me tRe u to Rul) i mus a py i t
lil o e u e y n d cin e , t t p l t o
al ei bl pr de s.Conve s y,i t De enda de i s no t
l lgi e ovi r
rel f he f nt cde t o
a y ghe M uli e Pr dur Pa ntRed ton Rulj t n i
ppl t
tpl oce e yme
uci
e, he t
c nnot a y i t a pr vi r Si e t De e nta e a
a
ppl t o ny o de . nc he f nda dopt d n
abirr prcie of NOT a yi ghe M uli e Pr dur
r tay a tc
ppl ng t
tpl oce e
Pa nt Re ton Rul t dignosi pr der, t n i i
yme
duci
el o a tc ovi s he t s
pr cuded fom a yi i t t ot r pr de s s h a t
el
r
ppl ng t o he he ovi r uc s he
Pl i if
a ntf .
( s . t5(mp ssi o ii al)
Re p a e ha i n rgn l.
UR He lh ra st sl tto it F o iasp ro a ij r p oe to saue a g n
at e d hi i ain n o l rd ' es n l nu y r tcin tt t, ruig
mi
t a t e saue i efi o sn te p e sy alw t i u e t a pl (h M utp e Pr c d r
h t h tt t t l s e o x r sl l he ns r r o p y t e lil o e u e
s d
o
Pa n Red to Ru11'( s a 1 )Ac or ngt UR He 1h,S t Dee ntee t t
yme t ucin e . Rep. t 0. c di o
'
at t he fnda lcs o
once
us (heMuli ePr edur Pa ntRe tonRulj t sat edoesnotalow i t a yi t
et
tpl oc e yme duci
e, he t ut
l t o ppl t o
onepr de whiea t s metmea birrl r us (i)t a pl i t ot rei bl pr vi r.'
ovi r l t he a i r ta iy ef e sc o p y t o he lgi e o des'
Thi i a i e esi a gume ,butby no me a mert i one.No pr son of
s s n nt r tng r
nt
ans
iorous
ovii
Fl i spes ij y prtci sauece tsac eofa tonwhe ea i ur a i t
orda' ronal nur oe ton ttt rae aus
ci
r n ns er pples he
Pa nt Reduc i Rul t s
yme
ton
e o ome pr de s but notot r .Nor doe UR He t pr de a
ovi r
he s
s
alh ovi ny
e r t xt ls
xta-e ua uppor f isi emr tton oft saut ort ne s a y pr m ie unde l ng t t
t or t nt ea i
he t t e he ce s r e s
ryi ha
i em r tton ie.t tc
nt ea i
. , ha onduc i pr hi t d unl se es l a horze
t s o bie
es xpr sy ut i d.
A le na i l Pr r s i post t t d he r alm otva i f t s l w s ti UR H e lh'
t r tve y, og e s ve is ha i e
t
i ton or hi a ui s
at s
a pae tr s nme t t t P o r sie alg d y d e n t a pl t e (h M ut e P o e t e
p rn e e t n ha r g e sv le e l o s o p y h te li r c dl
pl
r
Pa ntRe ton Rullt di tci ng medi lpr des' ( ot a 3 (mpha i i
yme
duci
e o agnosi/magi
ca ovi r.' M . t e
ss n
orgnal)Ho ve,Pr esi ac ur tl not t tSeve i UR He t wee cor c t t
ii l. we r ogr sve c aey es ha s l n f
g
a1h r re t ha
Pr r sve was not a yi t g uli e Pr edur Pa
ogesi
ppl ng he M tpl oc e yment Re ton Rul t
duci
ej o
dignosi i gi pr desa t tPr r sve mu ta y t g tpl Pr ed e Pa nt
a tc/ma ng ovi r nd ha ogesi
s ppl he Muli e oc ur yme
Re tonRul t s hpr vi r,t r woul bezeor i af dedt UR Heat asars t'
duci
el o uc o des hee
d
r elef for o
1h
e ul.
'
(d (mp a i i o i ial)I o h rwo d , v ni t esauerq rd P o rsi et u iiete
1 e h ss n rgn l. n t e r s e e f h tt t e uie r g e sv o tlz h
M uli e Pr e e Pa
tpl oc dur ymentReduc i Rul f di nosi a i ng pr de s UR He lh'
ton e or ag tc nd magi
ovi r ,
at s
t t lr mbur e twoul notcha
o a ei
s men
d
nge.
UR He l sfn la g me t z .t a e e i Flrd ' p ro a ij r p oe to sau e
at i a r u n- c, h t v n f o i as e s n l nu y r tcin ttt
h'
p nnte Pr g e sv t a pl t eg ut eP o e u ePa me tRe u to Rue fro l s me
e itd o r si e o p y h M lpl r c d r y n d cin ll o ny o
i
pr de s çtmus pr d a
ovi r , s
i
t ovi e dequae notc t t i ur dst ti wildo s ' f isf t s me
t
ie o he ns e ha t l
o' al or he a
r s .He e t UR He t ose i y i nt a ca e of a ton.Not ng i t gove i
ea ons r oo,
alh t nsbl nve s
us
ci
hi n he
m ng
saut orKo
tt e
uzme
nko' i ur nc polc r quiesPr es i t pr de s h notce oralows
s ns a e iy e r
ogr sve o ovi uc
i
l
UR He 1h t r ove i t a enc oft tno i .To bes e tesau esae t a Sani u e
at o ec r n he bs e ha tce
ur , h ttt tts h tt l ns rr
l
ma lm i pa
y i t ymenta a horz by t spar gr ph onl i t i ur e polc i l sa no i
s ut ied
hi a a
y f he ns anc
iy nc ude
tce
a t tm eofis e orr ne t tt i ur rm a lmi pa ntpur ua t t s he eof
t he i
s uanc
e wal ha he ns e y i t yme
s nt o he c dul
c ag s s cfe i ti p r g a h' Fl.Stt An j 6 77 6 *( ) Ho v r P oge sv
h r e pe iid n h s aa r p . a a. n. 2 .3 ( 5 . we e, r r sie
'
s tsi d t tr r m e by i l ng lnguag i Kouz e si ur nc polc r s r i t
aite ha equie nt ncudi a
en
m nko' ns a e iy e e vng he
rgh t utlz t M uli ePr e e Pa ntRt ton Rul
i t o ii e he
tpl oc dur yme
duc i
e.
l s t UR He 1h s e t r c
n hor,
at e ks o e overf a c e ofa ton t tdoe note s .I c nnot
or aus
c i ha
s
xit t a
pr vai u ra consr ton of t c
e l nde ny
tuci
he ompli bec us i has notplad c za e c am f
a nt a e t
e ogni bl l i or
y
'
r if Thus con r r t UR Heat sa ur s esi t tPr r sve sm oto t dim isi
ele .
, ta y o
lh' bs d ugg ton ha og es i '
in o s s s
pr m aur be a e i da nce a gume st tgo t t m e isoft cai s' t Cour mus
e t e c us t tdva s r
nt ha
o he rt
he l m , he
'
t t
dim ist c
s s he ompli .
a nt
Concl on
usi
Fort r a ons dic s i i ADJ
he e s
s us ed, t s
UDGED t tPr es i ' M oton t Dimi st
ha ogr sve s
i o s s he
Ame edCls Aci Compli ( E.1 ,fldonNove r15. 7i GRANTED.
nd
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