11 Fla. L. Weekly Supp. 929b
Insurance — Personal injury protection — Premature suit — Where insurer sent explanation of benefits requesting further information on charges and additional documentation, and medical provider did not produce requested information and documentation but served pre-suit demand letter and request to escrow, demand letter and request to escrow do not meet requirement to timely respond to request for information so as to allow filing of suit — Summary judgment granted in favor of insurer
WELLINGTON CHIROPRACTIC CENTER OF PALM BEACH, INC., Plaintiff, vs. NATIONWIDE MUTUAL INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 50-2004-SC-65 MB. August 3, 2004. Peter M. Evans, Judge. Counsel: Jeffery Vastola, West Palm Beach, for Plaintiff. Susan Kent, Law Offices of Capito & Polk, West Palm Beach, for Defendant.
FINAL SUMMARY JUDGMENT FOR NATIONWIDE
This cause having come before the Court on Defendant, Nationwide’s Motion for Summary Judgment on July 26, 2004, and the court having heard argument of counsel and being duly advised in the premises, finds as follows:
1. On October 31, 2003, Cheri Winchester was injured in an automobile accident.
2. At the time, Winchester had PIP coverage through a policy issued to her by Nationwide.
3. Following the accident, Winchester treated with Wellington Chiropractic.
4. On November 13, 2003, Nationwide received a bill from Wellington Chiropractic with fifteen itemized charges for dates of service 10/31/03-11/5/03.
5. On November 26, 2003, Nationwide made payment of some of the charges, however three charges were never paid and are at issue in this suit.
6. As to those three charges, Nationwide requested more information about the charges and/or requested back up documentation. The request for more information was sent to the provider in an Explanation of Benefits along with the November 26, 2003 payment.
7. The scope of the information requested by Nationwide — a detailed report to support the charge for the level of initial office visit billed, details on what “therapeutic activities” had been provided to the patient, and clarification on a charge for neuromuscular education which Nationwide deemed inconsistent with the doctor’s notes — falls within the scope of information a carrier can request under F.S. 627.736(b). See Kaminester v. State Farm, 775 So.2d 981 (Fla. 4th DCA 2000) and Physicians v. Progressive, 11 FLWS [Fla. L. Weekly Supp.] 649 (Orange County Court, 2004).
8. No medical records or other documents were produced by plaintiff in response to Nationwide’s inquiry prior to the service of plaintiff’s pre-suit demand letter and demand to escrow. Those demands were served on Nationwide on December 7, 2003.
9. Plaintiff’s pre-suit demand letter stated that plaintiff was seeking payment for the three outstanding charges. The pre-suit demand letter did not, however, specifically address the outstanding request for information.
10. Plaintiff asserts that since the demand letter was not accompanied by additional documentation, and served as notice to Nationwide of plaintiff’s intent to sue for these benefits without it having supplied additional records, the demand letter, by implication, was a response to Nationwide’s request and was sufficient under Florida Statute 627.736(6)(b) to allow the filing of this suit.
11. Alternatively, plaintiff argues that the records it first provided to Nationwide with its initial bill were sufficient and that it should not be required to submit additional documentation which it contends would be merely duplicative of that already provided.
12. While the court does not pass on the sufficiency or insufficiency of the medical records plaintiff provided to Nationwide, it does find that plaintiff’s pre-suit demand letter and demand to escrow do not meet the requirements of Florida Statute 627.736(6)(b) so as to allow the filing of this suit.
13. Florida Statute 627.736(6)(b) requires a provider to directly respond to timely requests for more information or documentation, and that a provider may not do so by omission or implication.
14. The purpose of the recent amendments to the PIP statute which standardized the submission of PIP claims was to reduce ambiguity as to what treatments were rendered to a patient, and to make it easier for insurers to understand exactly what for what medical services compensation was being sought. Bryant v. Direct General Insurance Company, 11 FLW [Fla. L. Weekly] Supp. 274 (Volusia Circuit Court, appellate decision, 2004).
15. To allow a provider to respond to a request for information in an indirect, ambiguous manner, or to do so by omission, would completely deflect and defeat the intent and purpose of the statute and its clear cut deadlines and requirements.
16. Under the law, a carrier is entitled to determine exactly what records were — and were not — provided in response to its demand for information so that it can, at the very least, evaluate the adequacy of the records and then make an informed business decision as to whether to pay a claim based on information it has, or litigate the matter and expose itself to the payment of plaintiff’s counsel’s fees if it is unsuccessful in that endeavor.
17. Because plaintiff did not provide a legally sufficient response to Nationwide’s timely request for information before filing suit, this claim is premature and Nationwide’s motion for summary judgment is granted.
IT IS THEREFORE ORDERED AND ADJUDGED that Defendant’s Motion for Summary Judgment is GRANTED. Plaintiff, WELLINGTON CHIROPRACTIC CENTER OF PALM BEACH, INC. shall take nothing by this action and the Defendant, NATIONWIDE MUTUAL INSURANCE COMPANY, shall go hence without day.
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