11 Fla. L. Weekly Supp. 1029a
Insurance — Personal injury protection — Medical provider who sought payment in individual capacity improperly submitted HFCA form and patient letter which contained tax identification number for corporation — Box 25 of HFCA form must contain true federal identification number of health care provider/supplier who rendered service, and Box 33 must contain name, address and telephone number of provider/supplier who is billing for actually rendering the medical services to the insured — However, insurer waived this defense by previously paying three bills when provider submitted HCFA forms with corporation’s federal tax identification number without notifying provider that they believed that the I.D. number did not belong to provider as an individual
DR. KEVIN L. PAYTON, (Larry Boyd), Plaintiff, v. PROGRESSIVE EXPRESS INSURANCE COMPANY, a Domestic Company, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 02-2789 COSO (60). August 12, 2004. Sharon L. Zeller, Judge. Counsel: Robert J. Fenstersheib, Hallandale. Matt Helman, Plantation.
ORDER
THIS CAUSE having come on to be heard on July 23, 2004 on Defendant’s Motion For Summary Judgment, and the court having heard argument of counsel, and being otherwise fully advised in the Premises, the court finds as follows:
1. On April 17, 2000, Mr. Larry Boyd was injured in an automobile accident. At the time of the accident Mr. Boyd was insured by Progressive Express Insurance Company. On or about May 20, 2002, plaintiff served defendant with a complaint seeking damages for failure to pay PIP benefits. An assignment of benefits that was attached to the complaint has a heading entitled: “ORAL-FACIAL RECONSTRUCTION AND IMPLANT CENTER OF SOUTH FLORIDA. Dr. Friedman, Dr. Payton, Dr. Cardenas.” In paragraph 3 of the assignment it states in part: “I hereby assign to Dr. Friedman, Dr. Payton or Dr. Cardenas any benefits under any policy of insurance ……….”
2. Plaintiff is an owner of the corporation, however the Plaintiff brought suit in his individual capacity. Box 25 of the HFCA form and the patient ledger contained a Tax I.D. Number for the corporation. Progressive Express Insurance Company paid three bills dated September 12, 2000, December 5, 2000 and April 19, 2001 for services rendered to this patient.
Law and Analysis
3. A medical provider/supplier cannot recover direct payment from an insurer under Florida Statutes, Section 627.736 when the medical provider/supplier knew or should have known that the information contained within the HCFA is false, misleading, incomplete or patently deceptive; or when it acts in deliberate ignorance of the truth, falsity or completeness of the information contained within the HCFA. Furthermore, a health care provider/supplier who negligently provides incorrect information, material of the nature of the services, location of the services, charge for the services, the amount of services or identity of the provider does not provide the insurer with notice of the loss or amount of same. Identity of the provider is material to the insurer’s decision as to whether to pay or deny a claim as a matter of law. New Hampshire Indemnity Co. vs. Equinox, 10 Fla. L. Weekly Supp. 172a (9 Cir. 2002).
4. Box 25 must contain the true federal identification number of the health care provider/supplier who rendered the service; Box 33 must contain the name, address and phone number of the health care provider/supplier who is billing for actually rendering the medical services to the insured.
5. The assignment of benefits is poorly drafted. Although the heading shows a name of a corporation the benefits are assigned to three doctors in their individual capacity.
6. In order for medical services to be considered to have been “lawfully rendered” pursuant to Florida Statute, section 627.736(5), the medical provider/supplier must render the medical services in compliance with the civil and administrative requirements of Florida and federal law. The term “render” as used in Florida Statute requires the person, corporation or other business entity that billed for the medical services to actually perform the medical services.
7. The Florida No Fault Statute is to be broadly construed in favor of the insured. The statute mandates that the insurer “shall not” be considered to have been furnished with written notice of the fact amount of a covered loss or medical bills due unless the statement for bills comply with Florida Statute, 627.736, as well as the billing standards recognized for HCFA 1500 promulgated by the Health Care Finance Administration. These provisions are designed to protect an insurer from improper billing and to otherwise prevent the unnecessary depletion of an insurer’s benefits.
8. The billing and notice requirements seek to protect the claimant from being billed for treatment rendered by non-licensed and non-qualified individuals. The information contained in the HCFA form provides an insurer with essential information so that the insurer can scrutinize and protect the insurer’s benefits and insure that medical services are being lawfully rendered.
Holding
9. That being said, Progressive paid three bills when Dr. Payton submitted the HCFA forms with the Federal Tax I.D. number of the corporation. This fact constitutes an intentional and involuntary waiver on the part of Progressive as to this defense. It was Progressive’s obligation, after an initial investigation, to notify Dr. Payton that they believed that the I.D. number did not belong to him as an individual. However, Progressive relied on this and repeatedly accepted bills without objection, and paid the bills as submitted. Therefore, Progressive knowingly and voluntarily waived its defense, and is now estopped from raising the defense under Florida Statute.
IT IS THEREFORE, ORDERED AND ADJUDGED that the Defendant’s Motion For Summary Judgment is hereby DENIED.
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