11 Fla. L. Weekly Supp. 258a
Insurance — Personal injury protection — Coverage — Denial — Exhaustion of policy limits on subsequent bills is not a defense to payment of timely filed reasonable, related, and necessary claim for medical services — Stay — Motion to stay case pending resolution of appeals of similar cases in three other circuits is denied — Summary judgment granted in favor of medical provider on exhaustion defense
A. J.P. SERVICES, INC. (Carol Vildor), Plaintiff, vs. NATIONWIDE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 02-20662-49. August 14, 2003. Kathleen D. Ireland, Judge. Counsel: Mary-Margaret Warren, Wites & Kapetan, P.A., Deerfield Beach, for Plaintiff. Sue Kent, West Palm Beach, for Defendant.
ORDER
THIS CAUSE having come on to be heard on August 5, 2003 on Plaintiff’s Motion for Summary Judgment for Exhaustion and Defendant’s Motion to Stay Proceedings and the Court having heard argument of counsel, reviewed the motion and case law presented by counsel, and being otherwise advised in the Premises, makes the following findings:
1. That plaintiff, A.J.P. SERVICES, INC., hereinafter “AJP”, is a health care provider which rendered services to CAROL VILDOR, hereinafter “VILDOR” on July 6, 2002 for injuries she allegedly sustained in a motor vehicle accident.
2. At the time of the accident, VILDOR, was covered by a policy of insurance issued by NATIONWIDE INSURANCE COMPANY hereinafter “NATIONWIDE” which provided $10,000 in PIP benefits.
3. VILDOR assigned her benefits under the above policy to AJP.
4. Based upon that assignment, AJP timely submitted a completed HCFA form for payment to NATIONWIDE. This request was rejected by an Explanation of Benefits dated August 5, 2002.
5. That the EOB cited as reasons for the nonpayment:
(1) incorrect coding
(2) alleged not a medical service provider and requesting W2 forms for employees
(3) Alleges not listed as clinic and requiring proofs of such and instructions on the procedure to appeal the decision.
6. That as of the date of the denial there were sufficient funds available for the full payment of the Plaintiff’s claim.
7. That on September 16, 2003 the insured PIP benefits were exhausted by payment to later submitted claims.
8. NATIONWIDE wishes to plead exhaustion of benefits as a defense to payment of AJP’s bills. To prevent the filing of a civil PIP suit because of exhaustion of benefits to quote: Pinnacle Medical v. Allstate, 5 F.L.W. [Fla. L. Weekly] Supp. 663a Fla. 17th Judicial Circuit (April 23, 1998) “would permit insurers to apply payments of medical bills in any manner it chose, and in some cases, to exhaust PIP benefits so as to deny payment to any medical providers who are not favored.” To deprive insureds of a right to sue contesting the method of the exhaustion would make the courts unwitting facilitators of insurers possible manipulation of PIP benefits.
9. Further, exhaustion of benefits does not preclude AJP’s lawsuit against NATIONWIDE in this case as, at the time AJP submitted its bills for payment there were sufficient funds in which to pay the full amount and later exhaustion of benefits is not a defense to payment of a timely filed reasonable, related and necessary claim for medical services.
10. NATIONWIDE ask this Court to stay proceedings alleging that exhaustion of benefits, prior to the filing of suit, bars the instant action even though there are numerous cases within the 17th Circuit which contradicts the argument. NATIONWIDE puts the Court on notice that a similar case is currently on appeal in different jurisdictions and asks this Court to therefore stay the proceedings hoping for a favorable decision.
11. This Court, with all due respect to the higher courts, would have to stay the majority of its thousands of PIP cases if the fact that an appeal to a higher court had been filed on a like issue was reason enough to halt the judicial process. Especially, where the issue is on appeal in 3 different circuits which could well result in conflicting authority.
It is therefore
ORDERED AND ADJUDGED as follows:
1. Defendant’s Motion to Stay these proceedings is Denied.
2. Plaintiff’s Motion for Summary Judgment is Granted.
3. Defendant’s fourth affirmative defense “Exhaustion of Benefits” is stricken with prejudice.
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