11 Fla. L. Weekly Supp. 362a
Insurance — Personal injury protection — Notice of loss — Timeliness — Provider/assignee which submitted HCFA form to insurer more than thirty days after date of service failed to provide insurer with notice of covered loss — Summary judgment granted in favor of insurer
TOTAL REHAB & MEDICAL CENTERS, INC., (Manuel Quintero), Plaintiff, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. Circuit Court, 17th Judicial Circuit in and for Broward County, General Jurisdiction Division. Case No. 01-025202 COCE 56. February 6, 2004. Linda R. Pratt, Judge. Counsel: Matt Hellman, Matt Hellman, P.A., Plantation. Rina Kaplan.
FINAL SUMMARY JUDGMENT FOR DEFENDANT PROGRESSIVE EXPRESS INSURANCE COMPANY
THIS CAUSE having come before the Court for hearing on January 22, 2004, on Defendant Progressive Express Insurance Company’s Motion for Final Summary Judgment, and the Court having reviewed the file, the deposition of record, including Defendant’s motion, heard arguments of counsel, and being otherwise fully advised in the premises, it is hereby
ORDERED AND ADJUDGED:
Nature of the Case
1. The Plaintiff, Total Rehab & Medical Centers, Inc. (“Total Rehab”), brought this action seeking recovery of personal injury protection (“PIP”) benefits under section 627.736, Florida Statutes. By its complaint, Total Rehab seeks recovery for medical services provided to Manual Quintero, the insured under an automobile policy issued by Defendant, Progressive Express Insurance Company (“Progressive”).
2. Progressive moved for summary judgment, asserting that Total Rehab was not entitled to payment of any PIP (or medical payment) benefits because the undisputed evidence of record establishes that Total Rehab did not timely provide Progressive of notice of a covered loss pursuant to Florida Statute 627.736(5)(b).
Findings of Fact
3. On August 24, 2000 claimant, MANUEL QUINTERO, alleged involvement in a motor vehicle accident in Florida.
4. The Plaintiff entered into an insurance contract with the Defendant, which provides personal injury protection benefits for the subject accident.
5. The policy provides Personal Injury Protection (“PIP”) benefits in the amount of $10,000 with no deductible.
6. As a result of the alleged injuries sustained in the accident, the Plaintiff received medical care from TOTAL REHAB & MEDICAL CENTERS, INC.
7. The claimant received services, from TOTAL REHAB & MEDICAL CENTERS, INC. starting September 6, 2000.
8. During that time period that the claimant was attending therapy, Defendant made timely payments for benefits billed on HCFA 1500 forms that were timely submitted pursuant to Florida Statute 627.736(5)(b).
9. The only HCFA bill at issue in this claim is for date of service October 19, 2000.
10. The HCFA bill for date of service 10/19/00 contained the date in box 31 of January 3, 2001. The total amount billed by Plaintiff for date of service 10/19/00 was $420.
11. Plaintiff’s HCFA for date of service November 27, 2000 contained in box 31 of said HCFA the date of 12/22/00.
12. Defendant received the HCFA for date of service 11/27/00 on 12/26/00.
13. Defendant timely issued the draft for date of service 11/27/00 on 1/23/01.
14. Plaintiff’s patient ledger documented the order in which HCFAs were entered.
15. Plaintiff’s patient ledger reflected that the HCFA for date of service 10/19/00 was entered after date of service 11/27/00.
16. Plaintiff has no other HCFA for a date of service 10/19/00 in the medical chart, other than the printout reflecting the date 1/3/01 in Box 31.
Conclusions of Law-Lack of Notice
17. The Court hereby adopts the foregoing findings of fact to the extent they encompass conclusions of law or mixed findings of fact and conclusions of law.
19. Florida Statute 627.736(5)(b) states in pertinent part:
With respect to any treatment or service, other than medicalservices billed by a hospital for services rendered at a hospital owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 30 days before the postmark date of the statement, except for past due amount previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment letter within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 60 days before the postmark date of the statement. The injured party is not liable for, and the provider shall not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph. . . .and the insurer shall not be considered to have been furnished with notice of the amount of covered loss for purposes of paragraph (4)(b) until it receives a statement complying with paragraph (5)(d), . . . .
20. The Court concludes that Total Rehab did not timely submit the HCFA to Progressive for date of service 10/19/00. Total Rehab’s untimely submission did not provide Progressive with notice of a covered loss.
21. Based upon the foregoing analysis, the Court concludes that Progressive is entitled to final summary judgment in this case. Specifically, the information before this Court shows that there is no genuine issue as to any material fact and that Progressive is entitled to a judgment as a matter of law.Final Judgment
IT IS HEREBY ADJUDGED that Plaintiff, Total Rehab & Medical Centers, P.A. (a/a/o of Manual Quintero), take nothing by this action and Defendant, Progressive Express Insurance Company, shall go hence without day and the Court retains jurisdiction for the purpose of taxing attorney fees and costs, as applicable.
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