10 Fla. L. Weekly Supp. 44a
Insurance — Personal injury protection — Insured’s action against insurer — Claim form — Insured’s itemized statement for medical treatment and letter to insurer failed to meet clear requirement of section 627.736(5)(e) to submit statements and bills for medical services on a HCFA 500 Form — Insured’s motion for summary judgment denied
SHARON BRYANT, individually and as parent and natural guardian of LAWRENCE STOKES, a minor, Plaintiff, vs. DIRECT GENERAL INSURANCE COMPANY, Defendant. County Court, 7th Judicial Circuit in and for Volusia County. Case No. 2001-12033-CODL. November 1, 2002. J.R. Smith, Judge. Counsel: Kim Simoes, Daytona Beach, for Plaintiff. Louis D. Kaye, Law Offices of Allen, Kopet & Associates, PLLC, Orlando, for Defendant.
[Approved at 11 Fla. L. Weekly Supp. 274a.]
ORDER
THIS CAUSE coming on before the court on Plaintiff’s Motion For Summary Judgment and after reviewing the pleadings and hearing arguments of counsel, the court finds as follows:
1. Review of Fla. Stat. 627.736 reveals a complex law that, when interpreted literally, seems to place a heavy burden on an insured, who has not assigned benefits under his/her insurance policy and who is seeking payment from an insurer for medical and other services. It would be fair to say that before an insured can receive payment under his/her insurance policy he/she be required to provide the following:
A. Reasonable proof of loss and the amount of expenses and loss incurred. Fla. Stat. 627.736(4).
B. Make sure that the Statement of Charges from a medical provider does not include charges for treatment or services more than 35 days before the postmark of the statement. Fla. Stat. 627.736(5)(c).
C. Make sure the Statement of Charges reflects charges that are reasonable and necessary. Fla. Stat. 627.736(1)(a).
D. Make sure the Statement of Charges follows the Physician’s Current Procedural Terminology. Fla. Stat. 627.736(5)(e).
E. Make sure the Statement of Charges is submitted to the insurer on a Health Care Finance Administration (HCFA) 1500 Form; UB 92 Form or any other standard form approved by the department. Fla. Stat. 627.736(5)(e).
F. Make sure the Statement of Charges does not include any charge in excess of the amount the provider charges for like services or supplies in cases involving no insurance. Fla. Stat. 627.736(5)(a).
G. Make sure that charges for medically necessary thermograms, spinal ultrasounds, extremity ultrasounds, video fluoroscopy, surface electromyography, nerve conduction tests, and magnetic resonance imaging meet the criteria and ceiling amounts in Fla. Stat. 627.736(5)(b)(2)(3)(4)(5).
2. Nevertheless, the language of the statute is clear and there is no glaring ambiguity in the statute. Fla. Stat. 627.736(5)(e) clearly states: “All statements and bills for medical services…shall be submitted” on a HCFA Form. The Plaintiff’s itemized statement for medical treatment and letter sent to the Defendant/Insurer on February 19, 2001 was not a part of, nor attached to, a HCFA Form. Plaintiff’s itemized statement and letter did not meet Fla. Stat. 627.736(5)(e) requirements. Submission of Plaintiff’s medical treatment on a HCFA 500 Form during the thirty-day period following the date of treatment is a clear requirement of the statute. The statute may seem to place an unfair burden on the insured. However, “the remedy is to seek a change in the law by legislative action, not judicial action in the guise of interpretation”. Fla Jury2nd Statutes , section 187. p500.
3. At the last hearing on this motion, Plaintiff abandoned its arguments on the issues of Defendant’s failure to comply with Fla. Stat. 627.7401 and 627.736(5)(c) and on the issue of Estoppel.
It is, therefore:
ORDERED AND ADJUDGED that Plaintiff’s Motion For Summary Judgment is DENIED.
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