11 Fla. L. Weekly Supp. 791d
Insurance — Medpay — Coverage — Denial — Where medical provider failed to give timely notice of claim for MRI to insurer, provider forfeited right to PIP benefits, insured was relieved of obligation to pay to provider charges that were unpaid due to provider’s failure to give timely notice of claim, and insurer was not legally responsible to pay those PIP benefits to insured — However, unavailability of PIP benefits does not preclude availability of medpay benefits, and statute does not dictate time for making medpay claims — Where medpay benefits are available to pay portion of MRI bill insured was legally obligated to pay, and insured was relieved of obligation to pay portion of bill that would have been paid by PIP benefits if claim had been timely submitted, medpay benefits are due for balance of MRI bill for which insured is still obligated — Summary judgment in favor of insurer reversed
DAWN LECONTE, Appellant, v. UNITED SERVICES AUTOMOBILE ASSOCIATION, Appellee. Circuit Court, 15th Judicial Circuit (Appellate-Civil) in and for Palm Beach County. Case No. 502003AP001668XXCCAY. L.C. Case No. 2002CC012780RF. July 14, 2004. Appeal from the County Court in and for Palm Beach County, Edward Rogers, Senior Judge. Counsel: Daniel A. Norton, Boca Raton, for Appellant. Miriam R. Merlo, Coral Gables, for Appellee.
[County court order at 10 Fla. L. Weekly Supp. 645a.]
(PER CURIAM.) Appellant, Dawn Leconte, appeals a summary judgment entered in favor of Appellee, United Services Automobile Association (“USAA”), on her claim for medical payment benefits under an insurance policy with USAA. We reverse.
On or about October 27, 1999, Leconte was injured in a motor vehicle accident. USAA had insured Leconte under a policy of insurance which included mandatory PIP coverage and optional medical payment benefits (“Policy”). Leconte had an MRI on June 12, 2001. Either she or her agent first gave USAA written notice of her claim on April 2, 2002. The record on appeal does not establish whether or when PIP benefits were exhausted. Leconte sued for medical payment benefits. USAA moved for summary judgment, claiming that the bill was not timely submitted to it and therefore no medical benefits payment was due. The trial court entered summary judgment in USAA’s favor.
Under Florida Statute §627.736(5)(b) (2001), USAA was “not required to pay . . . charges for treatment or services rendered more than 30 days before the postmark date of the statement . . .” Further, Leconte “is not liable for, and the provider shall not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph.” Fla. Stat. §627.736(5)(b) (2001). When the health care provider failed to give timely notice of the claim, it forfeited its right to PIP benefits and Leconte was relieved of the obligation to pay charges that are unpaid because of the provider’s failure to do so. Fla. Stat. §627.736(b)(5) (2001). See State Farm Mut. Auto. Ins. v. Warren, 805 So. 2d 1074, 1077 (Fla. 5th DCA 2002), rev. granted 826 So. 2d 994 (Fla. 2002) (“(s)ection 627.736(5)(b) seeks to remedy the absence of a notice requirement by requiring timely statements from medical providers so that a PIP insurer would be aware of the commencement of treatment and would be in a better position to assure that treatment is reasonable, related to the motor vehicle accident, or necessary.”). Under the Policy, USAA was obligated to “(p)ay damages for [bodily injury] . . . for which any covered person becomes legally responsible because of an auto accident.” (emphasis supplied). Since Leconte is not legally responsible to pay the portion of the bill which PIP would have covered had the claim been timely submitted, USAA is not required to pay the same portion, pursuant to its Policy provision.
USAA argues that Florida Statute §627.736(4)(f) (2001) controls the timing of medical payment benefits claims; that Leconte failed to comply with that section; and that her failure precludes recovery. We disagree. Florida Statute §627.736(4)(f) (2001) provides:
(m)edical payment insurance, if available in a policy of motor vehicle insurance, shall pay the portion of any claim for personal injury protection medical benefits which is otherwise covered but is not payable due to the coinsurance provision of paragraph (1)(a), regardless of whether the full amount of personal injury protection coverage has been exhausted. The benefits shall not be payable for the amount of any deductible which has been selected.
That subsection was added to legislatively alter the decision of the Third District in Blume v. American Motorist Insurance Co., 407 So. 2d 1046 (Fla. 3d DCA 1981) and to make clear that medical payment benefits are available to pay the insured’s 20% share when PIP coverage has not yet been exhausted. See Bolden v. State Farm Mut. Auto. Ins. Co., 689 So. 2d 339 (Fla. 4th DCA 1997). In other words, the statutory subsection confirms that the availability of PIP benefits does not preclude the availability of med pay benefits. USAA, though, would have us conclude that the opposite is also true, that there can be no med pay benefits absent PIP benefits. We do not agree. Florida Statute §627.736(4)(f) (2001) coordinates PIP and med pay benefits when both are available. It does not dictate a time frame for lodging med pay claims and, contrary to USAA’s argument, it modifies case law regarding the timing of medical payments benefits, not the time for making medical benefit payment claims. It simply has no application when PIP benefits are not available.
Medical payments coverage is optional. Consequently, the courts may not interfere with the terms of the parties’ contract. Moylan v. State Farm Mut. Auto. Ins. Co., 343 So. 2d 56 (Fla. 4th DCA 1977), superseded by statute as stated in State Farm Mut. Auto. Ins. Co. v. Swearingen, 590 So. 2d 506 (Fla. 4th DCA 1991); Bolden. Under the clear Policy terms, medical payments benefits are available to pay the portion of the disputed bill Leconte was legally obligated to pay. We know she was relieved of the obligation to pay whatever portion of the bill would have been paid by PIP if the claim had been timely submitted. She was not relieved of the obligation to pay the entire bill, though. Consequently, the Policy’s medical payment benefits are triggered.
We reverse the summary judgment and remand the action for proceedings consistent with this opinion. We deny USAA’s Motion for Attorney Fees and Costs. (MAASS, LEWIS, and WINIKOFF, JJ., concur.)
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