11 Fla. L. Weekly Supp. 246a
Insurance — Personal injury protection — Claim forms — Physician’s signature — Submission of properly completed HCFA 1500 form including signature of physician or supplier is condition precedent when making claim for PIP benefits — Summary judgment granted in favor of insurer
MIAMI MEDICAL GROUP, aso (Arnulfo Castillo), Plaintiff, vs. PROGRESSIVE SOUTHEASTERN INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 02-3693 SP 26 (01). January 14, 2004. Ellen Sue Venzer, Judge. Counsel: Rita Baez, for Plaintiff. Brenda Fam, Hengber, Goldstein, & Ray, P.A., Fort Lauderdale, for Defendant.
REVERSED. 12 Fla. L. Weekly Supp. 115b
FINAL JUDGMENT FOR PROGRESSIVE SOUTHEASTERN INSURANCE COMPANY
THIS CAUSE having come before the Court upon Defendant PROGRESSIVE SOUTHEASTERN INSURANCE COMPANY’S (hereinafter “PROGRESSIVE”) Motion for Final Summary Judgment against Plaintiff, MIAMI MEDICAL GROUP, a/s/o Arnulfo Castillo, (hereinafter “MIAMI MEDICAL GROUP”) and the Court having heard argument of counsel, and being otherwise duly advised in the premises, it is,
ORDERED AND ADJUDGED that there are no genuine issues of material fact in dispute and Defendant’s Motion for Final Summary Judgment may be entered as a matter of law. The undisputed facts show that on or about September 13, 2001 Arnulfo Castillo was involved in an automobile accident. As a result of the alleged accident, Mr. Castillo allegedly received treatment from the Plaintiff, MIAMI MEDICAL GROUP. Ultimately, MIAMI MEDICAL GROUP, submitted a Health Insurance Claim Form 1500 (“HCFA 1500”) for date of service January 10, 2002, in the amount of $600.00 to the Defendant, PROGRESSIVE.1
Box 31 of the HCFA 1500 requires the “SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS,” and further states “I certify that the statements on the reverse apply to this bill and are made a part thereof.” The HCFA 1500 submitted to PROGRESSIVE did not contain any “physician” or “supplier” signatures or degrees or credentials and did not contain any certification from the physician or supplier in Box 31 of the HCFA form. Box 31 merely contained a computer printed date: “01/22/02.” PROGRESSIVE did not tender payment for the claim and this lawsuit ensued.
The Court finds that as a condition precedent to MIAMI MEDICAL GROUP recovering personal injury protection benefits from an insurance company, all material provisions of the HCFA 1500 must be properly completed and this Court finds that Box 31 is a material provision of the HCFA 1500. Submission of a properly completed HCFA 1500 containing the basic fundamental information is a required condition precedent when making a claim for no fault benefits under Florida Statute, Section 627.736 (2001). Florida Statute, Section 627.736(5) sets out that HCFA 1500’s must be in accordance with the billing standards recognized by the “Health Care Finance Administration.”
The Health Care Finance Administration Form 1500, on its face, requires the “SIGNATURE OF PHYSICIAN OR SUPPLIER”. The submission of a HCFA 1500 that does not comply with the standards promulgated by the Department of Health and Human Services Carriers Manual, Health Care Financing Administration and Florida Statute, Section 627.736 does not put the insurer on notice of the fact of a covered loss. Health Insurance Claim Form Chapter II, Rule 2010, of record, provides that the signature of the provider or supplier must be entered, as well as the date that the HCFA 1500 was signed.
MIAMI MEDICAL GROUP did not provide PROGRESSIVE with “written notice of the fact of a covered loss”.2 An insurer is required to authenticate a claim, however there is no statutory duty imposed upon an insurer to cure a defective claim. MIAMI MEDICAL GROUP either purposefully elected or negligently failed to include the name and the signature of the “PHYSICIAN OR SUPPLIER” on the HCFA 1500. The Legislature, by requiring healthcare providers to utilize this form and the current CPT codes, did not intend to eliminate the requirement that as a condition precedent a claimant must provide “written notice of the fact of a covered loss.” Nor did the legislature intend that an insurer must investigate to discover the identity of the specific medical provider providing the treatment within the same thirty-day period to authenticate the claim.
MIAMI MEDICAL GROUP did not furnish PROGRESSIVE with a proper claim and notice of the fact of a covered loss as required by Florida Statute, Section 627.736(5)(d).
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 statements or bills comply with the Florida Statute, Section 627.736, as well as the billing standards recognized for HCFA 1500 and promulgated by the Health Care Finance Administration. These provisions are designed to protect an insured from improper billing and to otherwise prevent the unnecessary depletion of an insured’s benefits. The billing and notice requirements of Florida Statute, Section 627.736 seek to protect claimants from being billed for treatment rendered by non-licensed and non-qualified individuals, amongst other things. The signature of the physician or supplier on the HCFA 1500 is an integral part of establishing a covered loss, as it authenticates the claim information by specifying the named individual who is providing services and otherwise attesting that the services have actually been rendered is required. This is not optional. The information contained in the HCFA 1500 provides an insurer with essential information so that the insurer can scrutinize and better protect and preserve the insured’s benefits and assure that medical services are being lawfully rendered.
Accordingly, Box 31 of the HCFA 1500 must contain the identity and signature of the Physician or Supplier as well as the date signed and the failure of Plaintiff to do so is fatal to their claim as any attempt to resubmit the HCFA 1500 at this point would be fruitless, as it would be untimely submitted under Florida Statute, Section 627.736 and, therefore, non-compensable.
Accordingly, Defendant’s Motion for Final Summary Judgment is GRANTED in favor of Defendant, PROGRESSIVE SOUTHEASTERN INSURANCE COMPANY. Further it is ORDERED and ADJUDGED that Final Judgment is hereby ENTERED in favor of PROGRESSIVE SOUTHEASTERN INSURANCE COMPANY. The Plaintiff, MIAMI MEDICAL GROUP, aso (Arnulfo Castillo), shall take nothing by this action and Defendant, PROGRESSIVE SOUTHEASTERN INSURANCE COMPANY, shall go hence without day. The Court reserves jurisdiction to entertain Defendant’s Motion for attorney fees and/or costs.
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1Timeliness of submission of the charge and notice of intent to initiate litigation is not in issue.
2The record also shows that the Plaintiff failed to comply with rules and regulations set out by HCFA.
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