11 Fla. L. Weekly Supp. 675b
Insurance — Personal injury protection — Wage loss — Claimant is obligated to give actual notice of lost wage claim to insurer constituting reasonable proof of wage loss and amount of wage loss claim in form not requiring insurer to speculate concerning dates, times, and amount of lost wages — Amount of wage loss claim is not reasonably established by mere submission of HCFA forms by providers treating insured — Final summary judgment granted in favor of insurer
JAMES T. MCGARRIGLE, SR., Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Brevard County. Case No. 05-2001-CC-007919. April 8, 2004. George Turner, Judge. Counsel: Patrick Deese, for Plaintiff. Brenda K. Fam, Hengber, Goldstein & Ray, P.A., Fort Lauderdale, for Defendant.
FINAL JUDGMENT FOR STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
THIS CAUSE having come before the Court upon Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY’s Motion for Final Summary Judgment, and the Court having heard argument of counsel, and being otherwise duly advised in the premises, it is,
ORDERED AND ADJUDGED that Defendant’s Motion for Final Summary Judgment is GRANTED, and it is ADJUDGED that Final Judgment is ENTERED in favor of STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY. The Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY goes hence without day. The Plaintiff, James T. McGarrigle, Sr. takes nothing by his action.
This Defendant’s Motion for Final Summary Judgment raises the issue of statutory interpretation that is decided as a matter of law. Defendant’s Motion for Final Summary Judgment is based solely upon the admissions made by Plaintiff as contained in the Plaintiff’s deposition transcript, filed into the record; there are no material facts of record in dispute.
The undisputed facts show that the Plaintiff, James T. McGarrigle was in an automobile accident on October 30th, 2000. Plaintiff’s counsel wrote a letter to State Farm November 8, 2000, stating,
Dear PIP Adjuster:
Enclosed please find a properly completed PIP application for Florida No Fault Benefits and Wage and Medical Authorizations in connection with the above claim for PIP benefits. . . and in addition enclosed a lost wage verification form.
The lost wage verification form did not state any dates from which the Plaintiff contended he had lost time from work, did not contain the amount that the Plaintiff contended that he had lost in wages, nor did it contain the amount of income Plaintiff lost due to traveling to, and attending doctor visits. Further the name, address, and signature of Plaintiff’s employer was omitted from the lost wage verification form. The Plaintiff’s PIP application however indicated the Plaintiff’s employer’s name and address. The PIP application indicated that wages had been lost from the accident date, October 30th, 2000. The PIP application provided no information where the application requested the “amount” of wages lost and similarly provided no information where Plaintiff stated “unknown” for the dates from which the Plaintiff lost wages.
After receiving the PIP application State Farm timely followed up and contacted the Plaintiff’s attorney’s office and requested wage information. Plaintiff’s attorney did not provide State Farm with wage information to document the wage claim. State Farm thereafter contacted the Plaintiff’s employer, Telenet. State Farm ascertained from the employer that on the date of the accident, the Plaintiff was employed at Telenet Marketing. Telenet was at that time undergoing a shut-down and the accident occurred on the first day of the shut-down. The Plaintiff did not lose any wages from Telenet immediately following the accident as Telenet continued to pay the employees during the two week shut-down period. Plaintiff returned to work at Telenet when they re-opened their doors approximately two weeks post-accident, and Plaintiff’s salary was increased approximately two dollars per hour. State Farm did not pay the first two weeks of Plaintiff’s wages during the shut-down period pursuant to the Plaintiff’s employer’s representations that wages were not lost. However, the Telenet representative indicated that the Plaintiff had missed some time from work after returning from the shut-down to attend some doctor appointments. After speaking with Mr. Smith, Telenet’s representative, State Farm issued payment to the Plaintiff on December 4th, 2000 for the wages Telenet’s representative indicated that had been lost due to the Plaintiff attending doctor’s appointments.
Plaintiff’s medical providers continued to submit HCFA forms. However, State Farm did not receive a supplemental lost wage verification form, didnot receive a request for payment for the amount(s) continuing to accrue in lost wages after December 4th, nor was a letter submitted from Plaintiff’s counsel setting out the dates, wages, or amounts the claimant had incurred in lost wages subsequent to December 4th, 2002. Plaintiff contended that State Farm “should have known” that Plaintiff continued to lose wages because Plaintiff continued to receive treatment and that Defendant had an on-going duty to amass information from the employer to create a wage loss claim and that State Farm had a duty to recognize that a wage claim was accruing and calculate the amount of same. Pursuant to Fla. Stat. § 627.736 notice by a claimant of the amount due and what compensation is being claimed must be given to an insurer prior to a claim becoming due or overdue. State Farm contends that Plaintiff’s claim is premature and that Plaintiff’s claim has not yet ripened because benefits are not yet due or overdue pursuant to Fla. Stat. §627.736(4) and (4)(b).
This case raises an issue of statutory interpretation that can be decided as a matter of law regarding the argument that was provided
“WRITTEN NOTICE OF THE FACT OF A COVERED LOSS AND AMOUNT OF SAME” and “RECEIPT OF REASONABLE PROOF OF SUCH LOSS AND THE AMOUNT OF EXPENSES AND LOSS INCURRED”.
Florida’s Personal Injury Protection (“PIP”) Statute, section 627.736 provides, in relevant part:
(4) Benefits; when due. — Benefits due from an insurer under ss. 627.730-627.7405 shall be primary, except that benefits received under any workers’ compensation law shall be credited against the benefits provided by subsection (1) and shall be due and payable as loss accrues, upon receipt of reasonable proof of such loss and the amount of expenses and loss incurred which are covered by the policy issued under ss. 627.730-627.7405.
This section must be read in pari-materia sub-section (b) which provides that personal injury protection insurance benefits paid pursuant to this section shall be overdue if not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss and of the amount of same.
There are no material issue and, in fact both the Plaintiff and Defendant agree that an insurer has thirty days to authenticate a claim. Plaintiff concedes that they did not submit any items to State Farm identifying the amount(s) or identifying the dates claimed for the lost wages in this action. Plaintiff asserts that Defendant should have surmised that Plaintiff continued to lose wages and that submission of a HCFA form(s) to State Farm by the medical providers amounts to “reasonable proof of (wage) loss and the amount of same.” In reviewing the file and the statute the court finds that there is an obligation upon the claimant to give actual of notice of the lost wage claim to the Defendant, (other than HCFA forms indicating treatment by a medical provider) constituting reasonable proof of wage loss (other than HCFA forms indicating treatment by a medical provider) and the amount of the claimed wage loss claim. This must be done in a form that does not require Defendant to speculate or guess as to dates and times and amount of Plaintiff’s lost wages. A wage loss claim is no different than a medical claim; requires that reasonable written notice be given. [“When a claimant doesn’t provide the medical bills at issue prior to filing a lawsuit then the insurer has no obligation to pay.”] Gauvre v. Fortune Ins. Co., 4 Fla. L. Weekly Supp. 380a (17th Judicial Circuit, Appellate capacity in and for Broward County 1995). The amount of a wage loss claim is not reasonably established by the mere submission of a HCFA form from a medical provider. A claim for wages or other benefits should be clear on its face and presentment should not be an enigma for the claims representative to decipher. Although the definition of “reasonable proof of loss” is not contained in the Florida No Fault Act, notice and documentation of a loss is required, whether it consists of tax returns or affidavits supporting the amount of income loss. 2-16 NFUNN § 16.00 See damages in Tort Actions Ch 47, No-Fault Automobile Ins. (Mathew Bender.) Claiming No Fault Benefits is a continuous procedure rather than a single event. State Farm Mutual Automobile Insurance Company v. Lee, 678 So.2d 818 (Fla. 1996). In the instant case, Plaintiff has conceded that they did not submit to Defendant any documents or specific request for lost wage which is the subject of this suit. The Defendant cannot authenticate written notice of a covered loss when none has been given by the Plaintiff.
Accordingly, the court reserve jurisdiction to entertain Defendant’s Motion for attorney fees or costs.
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