12 Fla. L. Weekly Supp. 491a
Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Insurer’s motion for summary judgment arguing that medical provider’s noncompliance with EOB request for records and information constitutes failure to satisfy condition precedent to suit is denied where there is factual issue as to whether insurer requested additional information within 30 days of receipt of invoices — Insurer is entitled to partial summary judgment as to facts that information was requested and that provider failed to provide anything in response to request
DR. FIDEL S. GOLDSON, D.C., P.A., (a/a/o Damaris D. Villar), Plaintiff, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 03-9554 COCE 53. February 18, 2005. Robert W. Lee, Judge. Counsel: C. Glen Ged, Boca Raton, for Plaintiff. Steven J. Leiter, Fort Lauderdale, for Defendant.
ORDER GRANTING IN PART DEFENDANT’S AMENDED MOTION FOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on February 14, 2005 for hearing of the Defendant’s Amended Motion for Partial Summary Judgment, and the Court’s having reviewed the Motion and entire Court file; heard argument; reviewed the relevant legal authorities; and been sufficiently advised in the premises, finds as follows:
Background: This is an action for unpaid PIP benefits. The Defendant received several invoices from the Plaintiff for which it denied or reduced coverage, while providing an explanation of benefits. The Defendant now moves for summary judgment for these particular items. As the undisputed facts show, they can be summarized as follows:
1. Supplies. A total of 7 supplies were billed for work done on January 15, 2003; one supply for work on February 6, 2003; and one supply on April 4, 2003. The insurer requested additional information as to each supply. The Plaintiff did not provide it. At deposition, Dr. Goldson stated that he did not believe he was obligated to supply any further information for this item.
2. Therapeutic Activities. The Plaintiff billed for therapeutic activities under CPT code 97530 on 23 different dates. In response, the insurer requested the Plaintiff to “describe what techniques or tasks were used in the performance of therapeutic activities.” The doctor did not do so until after he filed the suit, when it was discerned that the therapeutic activity at issue was “stretching.”
3. Activities for Daily Living. The doctor submitted an invoice for work done on January 17, 2003 and January 22, 2003 under CPT code 97540. The insurer declined payment, noting that the doctor had used a CPT code which no longer existed. The doctor did not provide any corrected invoice for this work.
4. Functional Capacity Testing . The doctor submitted an invoice which included 6 separate entries on one day, February 4, 2003, under CPT code 97750. This CPT code requires a billing in intervals of 15 minutes. The insurer paid for 3 entries (45 minutes), but declined to pay the balance until it was provided “a letter detailing the time for each specific section of the test.” Nothing further was received from the doctor.
5. Grip Strength Test. The doctor submitted an invoice which included a single entry on January 30, 2003 under CPT code 95832. The insurer declined to pay, noting that the doctor failed to provide “a report for the services rendered or your report does not possess the necessary information to process the claim. Please provide a report.” Nothing was produced.
6. Evaluation. The doctor submitted an invoice which included $250.00 for work done on February 22, 2003 under CPT code 99214. The insurer declined to pay, noting that “it seems that the service [. . .] performed has not fulfilled the requirements of code 99214.” A letter was requested for reconsideration, which was not provided by Dr. Goldson.
7. Final Evaluation. The doctor submitted an invoice which included $300.00 for work done on April 8, 2003 under CPT code 99215. The insurer requested medical records to evaluate the claim, which was not provided prior to suit.
As noted, it is undisputed that Dr. Goldson did not provide anything to the insurer in response to these requests.
Defendant seeks a partial summary judgment that the payment for these bills was not “overdue” prior to suit, and as a result, the Plaintiff has failed as a matter of law to comply with a condition precedent prior to suit.
Conclusions of Law: When an automobile insurer requests a medical provider to furnish written documentation in support of its charges, Florida law requires the provider to do so. Fla. Stat. §627.736(6)(b)(2001). Additionally, when an insurer makes a written request for the claimant’s medical records within thirty days of receipt of the invoices, the amount due the provider does not become overdue until expiration of the 30-day time period allowed in subsection (4)(b), or until the expiration of ten days from the insurer’s receipt of the requested information, whichever occurs later.
The Defendant argues then that because payment cannot become overdue until the expiration of either the statutory 30-day time period or the expiration of 10 days from the insurer’s receipt of the Plaintiff’s records, the provider’s compliance operates as a condition precedent to filing suit for these particular invoices. Although the Defendant’s position of law may be well taken, it is of no avail in this particular case because a disputed issue of material fact continues to exist as to whether the insurer requested the additional information within 30 days of receipt of the invoices. If the insurer did not timely request the material, then the further legal analysis suggested by Defendant is not triggered.
Nevertheless, Defendant is entitled to partial summary judgment pursuant to Rule 1.510(d) on the factual matters set forth in numbered paragraphs 1-7 above, as well as the fact that Dr. Goldson failed to provide anything in response to the Defendant’s request. These material facts have been established without substantial controversy, and at any further hearing or trial in this case, these facts shall be deemed established without the necessity of any further evidence or argument. Accordingly, it is hereby
ORDERED AND ADJUDGED that Defendant’s Motion for Partial Summary Judgment is granted in part as set forth hereinabove.
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