12 Fla. L. Weekly Supp. 162b
Insurance — Personal injury protection — Demand letter — Where medical provider failed to mark and tabulate CPT codes and charges on health insurance claim forms attached to demand letter so as to specify each exact amount at issue for each individual charge at issue and provide accurate total amount claimed to be due, claim forms were insufficient as itemized statement, and provider failed to comport with all material requirements of demand letter — Final summary judgment in favor of insurer granted
CHIRO-MEDICAL REHABILITATION OF ORLANDO, INC., (PAUL SCOTT), Plaintiff, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 03019684 COCE 49. October 15, 2004. Kathleen Ireland, Judge. Counsel: Jose Pete Font. Chris Fisher.
FINAL SUMMARY JUDGMENT FOR DEFENDANT PROGRESSIVE EXPRESS INSURANCE COMPANY
THIS CAUSE having come before the Court for hearing on October 10, 2003, on Defendant Progressive Express Insurance Company’s Motion for Final Summary Judgment, and the Court having reviewed the file, the 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, Chiro-Medical Rehabilitation of Orlando, Inc. (a/a/o Paul Scott), brought this action seeking recovery of personal injury protection (“PIP”) benefits under section 627.736 of the Florida Statutes.
2. Progressive moved for summary judgment, asserting that Chiro-Medical Rehabilitation of Orlando, Inc. (a/a/o Paul Scott) was not entitled to maintain the cause of action against the Defendant, since prior to the filing of suit, the Defendant was not provided with a Demand Letter that comported with all the material requirements of Fla. Stat. 627.736(11).
Findings of Fact
3. The facts material to Progressive’s motion for summary judgment are undisputed and established by the pleadings and depositions of record. The material facts are set forth below.
4. On or about March 21, 2003, the Insured, Paul Scott, was said to have sustained injuries in an automobile accident.
5. The Plaintiff began treating the Insured on March 25, 2003, for injuries said to have been related to March 21, 2003 automobile accident.
6. On March 25, 2003, the Insured issued an assignment in the Plaintiff’s favor for personal injury protection benefits that he was entitled to as a result of the March 21, 2003 automobile accident.
7. Treatment by the Plaintiff of the Insured continued until June 9, 2003.
8. During the course of treatment, the Defendant reduced and denied a number of service charges that were submitted by the Plaintiff.
9. On August 20, 2003, claiming that the Defendant had made improper denials and reductions, the Plaintiff issued a letter to the Defendant that was titled “DEMAND LETTER Pursuant to Florida Statute Section 627.736(11).”
10. The Demand Letter was addressed correctly, contained the name of the Plaintiff, the name of the Insured, the Date of loss, the correct claim number, and stated that the itemized statement consisted of the Health Insurance Claim Forms that were attached to the demand letter.
11. None of the Health Insurance Claim Forms that were attached to the Demand Letter were marked in any way so as to allow the Defendant to be able to distinguish which charges the Plaintiff was disputing as having been improperly reduced or denied.Conclusions of Law — Demand Letter pursuantto Fla. Stat. 627.736(11)
12. 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.
13. Fla. Stat. 627.736(11) provides in pertinent part:
11) Demand letter. —
(a) As a condition precedent to filing any action for benefits under this section, the insurer must be provided with written notice of an intent to initiate litigation. Such notice may not be sent until the claim is overdue, including any additional time the insurer has to pay the claim pursuant to paragraph (4)(b).
(b) The notice required shall state that it is a “demand letter under s. 627.736(11)” and shall state with specificity:
1. The name of the insured upon which such benefits are being sought, including a copy of the assignment giving rights to the claimant if the claimant is not the insured.
2. The claim number or policy number upon which such claim was originally submitted to the insurer.
3. To the extent applicable, the name of any medical provider who rendered to an insured the treatment, services, accommodations, or supplies that form the basis of such claim; and an itemized statement specifying each exact amount, the date of treatment, service, or accommodation, and the type of benefit claimed to be due. A completed form satisfying the requirements of paragraph (5)(d) or the lost-wage statement previously submitted may be used as the itemized statement . . .
14. The Court concludes that although the statute states that Health Insurance Claims Forms can be used as an itemized statement, the Plaintiff in the present case did not comport with all the material requirements of a demand letter made pursuant to Fla. Stat. 627.736(11).
15. This court holds that unless the Plaintiff is claiming the full amount set forth in all the Health Insurance Claim Forms that are attached to the Demand letter, then, more specificity is required.
16. If the Health Insurance Claim Forms are to be used as an itemized statement, and all charges contained in the Health Insurance Claim forms have not been denied or reduced, the Plaintiff must mark and tabulate the CPT codes and charges contained in the Health Insurance Claim forms accordingly so as to specify each exact amount at issue for each individual service charge at issue, along with an accurate account of total amount that is being claimed as due.
17. In the present case the Defendant was not afforded proper notice of the amount at issue.
18. As a matter of public policy it is of paramount importance that the Demand Letter requirements of Fla. Stat. 627.736(11) are strictly adhered to. Allowing medical care providers to loosely adhere to the Demand Letter requirements would unquestionably cause the price of automobile insurance to increase because of the additional costs that would result from litigation that could have been avoided by the insurer and the provider if the insurer would have been given a fair representation of the true amount at issue. It is unfortunate reality that in the processing of medical claims mistakes will at times be made by both the insurer and the medical care provider. Thus, to mitigate the negative consequences of such inevitable mistakes, legislatively prescribed safeguards must be strictly adhered to for the benefit of the insured, medical care provider, and the insurer.
Final Judgment
IT IS HEREBY ADJUDGED that Plaintiff, Chiro-Medical Rehabilitation of Orlando, Inc. (a/a/o Paul Scott), 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 determining any motion by Defendant to tax fees and costs.
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