11 Fla. L. Weekly Supp. 443c

Insurance — Personal injury protection — Coverage — Late submitted bill — Bill submitted to wrong entity — Where due to erroneous information provided by insured, provider/assignee timely billed insured’s former insurer, former insurer denied claim, and provider promptly resubmitted claims upon receipt of correct insurance information more than thirty days after dates services were rendered, provider may recover benefits pursuant to 2001 amendment to PIP statute — Summary judgment granted in favor of provider — Explanation of benefits applying claim to insured’s deductible did not operate as denial and, according, provider was required to submit demand letter

PROFESSIONAL MASSAGE SERVICES, INC., as Assignee for LISA CLIETT, Plaintiff, vs. PEACHTREE CASUALTY INSURANCE COMPANY, a Florida Corporation, Defendant. County Court, 4th Judicial Circuit in and for Duval County. Case No. 2002-6340-SP. Division D. March 1, 2004. Russell L. Healey, Judge. Counsel: Joseph V. Camerlengo and R. Brian Boyd, Camerlengo & Brockwell, P.L., Jacksonville, for Plaintiff. R. Steven Ruta, Barrett, Chapman & Ruta, P.A., for Defendant.

Circuit court’s affirmance (unpublished) of summary judgment quashed at 31 Fla. L. Weekly D708a.[

ORDER ON PLAINTIFF’S AND DEFENDANT’S CROSSMOTIONS FOR SUMMARY JUDGMENT

THIS CAUSE came on to be heard on November 24, 2003, before the Honorable Russell L. Healey, upon Plaintiff’s and Defendant’s Cross Motions for Summary Judgment, and the Court, having heard arguments from counsel for the parties and being otherwise further advised of the premises, it is ORDERED as follows:

The Court makes the following findings of fact and conclusions of law:

A. The following two issues were presented to this Court:

1.Whether Section 627.736(5)(b), Florida Statutes (1998), allows Plaintiff to recover No-Fault benefits when an insured fails to furnish the medical provider with the correct name and address of his/her PIP insurer, where the medical provider timely submits bills to the incorrect insurance company and later, upon receiving the correct insurer information, timely resubmits the bills to the correct insurance company; and

2. Whether Section 627.736(11), Florida Statutes (2001), requires Plaintiff to furnish Defendant with a demand letter when Defendant acknowledges receipt of the bill and wrongfully applies the claim to the insured’s deductible.

B. Prior to the hearing, the parties stipulated to the following facts, among others:

1. On or about June 26, 2001, Lisa Cliett was involved in an automobile accident in Duval County, Florida.

2. At the time of the accident, Ms. Cliett was insured under a Peachtree automobile insurance policy providing $10,000 in No-Fault/PIP benefits, subject to a $2,000.00 deductible.

3. At her initial treatment with Plaintiff, Ms. Cliett provided erroneous insurance information for her prior automobile insurer, Dairyland.

4. Based on the erroneous insurance information from Ms. Cliett, Plaintiff timely billed Dairyland for the reasonable and necessary medical services rendered to Ms. Cliett from June 28, 2001 through September 17, 2001 in compliance with Section 627.736(5)(b), Florida Statutes (1998).

5. Dairyland Insurance Company denied Plaintiff’s claims on the grounds that it did not insure Ms. Cliett at the time of the accident.

6. On October 5, 2001, Plaintiff discovered Defendant Peachtree was the correct insurance company.

7. On October 9, 2001, within four (4) days of determining that Defendant Peachtree was the correct PIP insurance carrier, Plaintiff re-submitted the bills to Defendant, which Plaintiff had previously submitted to Dairyland.

8. On October 15, 2001, Peachtree received fifteen (15) HCFA claim forms from Plaintiff reflecting reasonable and necessary medical services provided to Ms. Cliett for injuries sustained in her June 26, 2001 motor vehicle accident.

9. Of the fifteen (15) HCFA claim forms received on October 15, 2001, twelve (12) of the forms reflected reasonable and necessary medical services rendered on June 28, 2001 through September 6, 2001, totaling $1035.00. Defendant Peachtree denied payment for these dates of service because they were not submitted within 30 days from the dates the services were actually rendered.

10. On December 12, 2001, Peachtree received one (1) additional HCFA claim form from Plaintiff reflecting reasonable and necessary medical services rendered on November 21, 2001, totaling $45.00. Defendant applied this claim to Ms. Cliett’s deductible at the 80% statutory rate.

11. Defendant did not receive a notice of intent to initiate litigation from the Plaintiff for the claims relating to services at issue rendered after October 1, 2001.

C. Findings

1. First, this Court finds that the legislature amended Florida Statute section 627.736(5) in 1998 adding subsection (b), which provided a 30-day time limit in which to submit certain medical billing to a PIP carrier. The purpose of the amendment was to reduce bulk billing and to provide the insurer a reasonable opportunity to assure that the medical treatment provided is reasonable, necessary and related to the motor vehicle accident. See State Farm Mutual Automobile Insurance v. Warren, 805 So.2d 1074 (Fla. 5th D.C.A. 2002) (finding section 627.736(5)(b)(1998) constitutional). The Court notes that this is not a case of “bulk billing” by Plaintiff. Defendant denied Plaintiff’s claims only because they were not submitted within 30 days from the date the services were actually rendered. Defendant stipulated the treatment was reasonably, necessary and related to the motor vehicle accident. Accordingly, the problems that the legislature intended to protect against when creating Florida Statute section 627.736(5)(b)(1998) are not frustrated by allowing Plaintiff to recover in the present case for No-Fault benefits.

2. This Court finds the legislature’s 2001 amendment to Florida Statute Section 627.726(5)(b)(1998), which is now renumbered to section 627.736(5)(c) provides an exception to the rigid 30 day billing requirement by allowing medical providers a second chance to bill a PIP insurer in the limited circumstance where the provider is furnished incorrect insurance information by the patient, timely bills the wrong insurer and then timely submits the bills upon learning of the correct no-fault insurer. This Court recognizes that statutory provisions under Florida’s No-Fault laws will be liberally construed in favor of the insured. See, e.g., United Automobile Insurance Co. v. Viles, 726 So.2d 320 (Fla. 3rd D.C.A. 1998).

3. Taking Defendant Peachtree’s interpretation of the PIP statute to its logical conclusion results in significant inequities that could not have been contemplated by the Florida Legislature’s amendments when adding the 30-day billing deadline. First, the insurance company that has been receiving premiums for PIP coverage would not have to pay for reasonable and necessary medical treatment rendered to its insured. Second, the medical provider would be prohibited from collecting any money for reasonable and necessary medical treatment from the insurance company and would be prohibited from collecting any money from the insured/patient who provided the incorrect insurance information. In the present case for No-Fault benefits, such a result would be patently unfair to the innocent medical provider who timely submitted bills based on erroneous insurance information from the insured/patient.

Accordingly, it is ORDERED AND ADJUDGED:

1. Plaintiff’s Motion for Summary Judgment is GRANTED IN PART. Plaintiff shall recover no-fault benefits pursuant to Section 627.736(5)(b), Florida Statutes (1998), where Plaintiff promptly re-submitted the previous timely submitted claims for medical services upon receipt of the correct insurance information. All other portions of Plaintiff’s Motion for Summary Judgment is hereby DENIED; and

2. After applying Plaintiff’s $2,000.00 deductible, Defendant shall pay $612.00 to Plaintiff in no-fault benefits plus $155.75 in interest for which let execution issue;

3. Defendant’s Motion for Summary Judgment is GRANTED IN PART. Defendant’s explanation of benefits applying the claim to the insured’s deductible did not operate as a denial. Therefore, Plaintiff was required to submit a demand letter in accordance with Section 627.736(11), Florida Statutes (2001). All other portions of Defendant’s Motion for Summary Judgment is hereby DENIED; and

4. The Court reserves Jurisdiction to address the amount of taxable costs and attorney’s fees to be awarded to Plaintiff.

* * *