11 Fla. L. Weekly Supp. 366a
Insurance — Personal injury protection — Coverage — Reasonable and necessary expenses — Documentation — Where insurer receiving claim for Flex L.S.O. Support sent medical provider Explanation of Benefits within 30 days requesting invoice indicating amount provider paid to supplier for device, provider did not provide insurer with invoice until over 22 months into litigation, and insurer paid full amount of disputed bill plus interest within ten days of receipt of invoice, summary judgment is entered in favor of insurer
MEDPEND, INC., as assignee of PHILLIP PRATT, Plaintiff, vs. NATIONWIDE MUTUAL FIRE INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 01-SC-3716-19-U. February 16, 2004. Donald L. Marblestone, Judge. Counsel: Jayson Zortman, for Plaintiff. R. Scott Simmons, Law Offices of Capito & Polk, Longwood.
ORDER ON DEFENDANT’S SECOND MOTION FOR FINAL SUMMARY JUDGMENT AND PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT AS TO ENTITLEMENT TO ATTORNEY’S FEES
This action was heard December 8, 2003 on Defendant’s Second Motion for Final Summary Judgment and Plaintiff’s Motion for Partial Summary Judgment as to Entitlement to Attorney’s Fees, and after argument from both parties:
IT IS ORDERED AND ADJUDGED that:
1. Defendant’s Second Motion for Final Summary Judgment is Granted.
2. Plaintiff’s Motion for Partial Summary Judgment as to Entitlement to Attorney’s Fees is Denied.
3. The insured, Phillip Pratt, was involved in an automobile accident on July 9, 2001.
4. At the time of the motor vehicle accident, Philip Pratt had Personal Injury Protection insurance with Nationwide Mutual Fire Insurance Company (hereinafter “Nationwide”) that was in effect at the time of the accident.
5. Philip Pratt sustained injuries as a result of the automobile accident and was prescribed a Flex L.S.O. Support by Alyn Benezette, D.O.
6. Pursuant to the prescription, the Plaintiff provided a Flex L.S.O. Support to Philip Pratt on October 12, 2001, and billed Nationwide $1,125.00 for the service.
7. Nationwide received the health insurance claim form (hereinafter “HCFA”) regarding the October 12, 2001 date of service on October 22, 2001.
8. Upon receipt and review of the HCFA, Nationwide sent an Explanation of Benefits (hereinafter “EOB”) to Plaintiff on November 6, 2001 requesting an invoice indicating the amount the Plaintiff paid to the supplier or manufacturer of the Flex L.S.O. Support so that Nationwide could make a reimbursement determination under its obligation to pay reasonable expenses for necessary medical care and to maximize benefits for its insured, Philip Pratt.
9. Nationwide requested the invoice in order to evaluate its obligation to pay for reasonable expenses for medically necessary care under Florida Statute §627.736(4)(a) and (4)(b).
10. It is Nationwide’s right to discover Plaintiff’s costs for the product if billed to Nationwide in order to maximize its insured’s benefits.
11. Nationwide timely made its written request via the EOB within thirty (30) days after receiving notice of the covered loss by the Plaintiff.
12. Plaintiff filed the above-styled action on December 11, 2001. At the time the lawsuit was filed, Plaintiff had not provided, nor had Nationwide received, an invoice indicating the cost of the Flex L.S.O. Support provided to Philip Pratt.
13. Florida Statute §627.736(6)(b) clearly states that an insurer has a right to request invoices from medical providers for the purpose of obtaining the cost and providing supplies to an insured.
14. The Plaintiff did not provide Nationwide with an invoice as set forth in the EOB until September 30, 2003, which was over twenty-two (22) months into litigation.
15. Specifically, after receiving the invoice, Nationwide made payment for the October 12, 2001 date of service in the amount of $1,125.00 plus $254.28 in interest on October 9, 2003.
16. Nationwide is only required to pay the amount, or the partial amount, of a covered loss to which such documentation relates in accordance with Paragraph (4)(b) or within ten (10) days after the insurer’s receipt of the requested documentation, whichever occurs last. §627.736(6)(b), Florida Statutes.
17. Pursuant to Florida Statute §627.736(6)(b), Nationwide was not required to make payment until ten (10) days after it received the requested documentation from the Plaintiff.
18. In the case at bar, Nationwide timely made full payment within (10) days of receiving the invoice in compliance with Florida Statute §627.736(6)(b).
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