12 Fla. L. Weekly Supp. 161b
Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Sufficiency — Where, rather than setting forth precise reason for denial of claim, insurer’s letters set forth verbatim roster of statutes, letters failed to meet statutory requirements for EOB — In failing to comply with statutory requirement to provide itemized specification for declined claims, insurer breached insurance contract — Partial summary judgment entered in favor of medical provider as to liability
FIDEL S. GOLDSON, D.C., P.A. (a/s/o John Gray), Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 03-7459 COSO 62. November 18, 2004. Robert W. Lee, Judge. Counsel: Russel Lazega, The Law Office of Russel Lazega, North Miami, for Plaintiff. Thomas Freehling, Coral Gables, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT (COUNT I)
THIS CAUSE came before the Court on November 2, 2004 for hearing of Plaintiff’s Motion for Summary Judgment (Count I), and the Court’s having reviewed the Motion and entire Court file; reviewed the relevant legal authorities; heard argument, and been sufficiently advised in the premises the Court finds as follows:
Background:On October 24, 2003, the Plaintiff filed its Complaint against Defendant for breach of contract. The gist of the Count at issue is that the Defendant failed to provide the explanation of benefits required by Florida Statute §627.736(4)(b). The undisputed evidence indicates that the Defendant sent the Plaintiff a series of three letters which it claims meets the statutory requirement. The letters are identical in format, with only the date of services and amount of claim being different.
Each letter lists the insured’s name, claim number, policy number and date of loss. Additionally, each letter parrots the language of six statutes which it believes establishes that the submitted claim “does not qualify as a written notice of a covered loss.” None of the letters specifically set forth why the particular claim is being denied.
The Plaintiff claims that the provisions of Florida Statute §627.736(4)(b) have become part of the insurance contract through operation of law. The Plaintiff further argues that “[t]he clear requirement of [the statute] is to require insurers who deny a medical charge to specify the denied charge, the reason for denial and provide contact information to the party [whose] claim is denied so that person or party can respond or contest the denial.” Because the insurer failed to provide such a response, the Plaintiff concludes that the Defendant is in breach of contract.
Conclusions of Law. As pertains to the issue in this Motion, Florida Statute §627.736(4)(b) provides: “When an insurer pays only a portion of a claim or rejects a claim, the insurer shall provide at the time of the partial payment or rejection an itemized specification of each item that the insurer had reduced, omitted, or declined to pay and any information that the insurer desires the claimant to consider related to the medical necessity of the denied treatment or to explain the reasonableness of the reduced charge, [. . .]; and the insurer shall include the name and address of the person to whom the claimant should respond and a claim number to be referenced in future correspondence” (emphasis added). This is generally informally referred to as an “explanation of benefits.” The statute does not further define what is meant by an “itemized specification.”
Under Florida law, in the absence of a statutory definition, a word used in a statute is given its standard dictionary definition. See Alvarez v. State, 800 So.2d 237, 238 n.4 (Fla. 3d DCA 2001). The word “specification” is defined as “a detailed precise presentation of something,” and “the act or process of specifying.” The word “specify” is defined as “to name or state explicitly in detail.” Webster’s New Collegiate Dictionary 1108 (1980).
In the instant case, the insurer has denied the claim in total. The question then for the Court is whether the letters provided by the insurer “state explicitly in detail” why the insurer declined to pay the claim. Here, rather than setting forth the precise reason for denying the claim, the insurer sets forth verbatim a roster of statutes leaving it up to the insured to guess which provisions truly apply to the particular denial of claim and why. Under no reading of the word “specification” does the language of the insured’s letters meet the requirements of the statute. Rather than “explicitly stating” the reason for the denial, the insured’s response to the claim does nothing more than confuse the matter even further. As a result, the Court finds that there is no disputed issue of material fact on this issue. As a matter of law, the Defendant’s response does not come close to meeting the requirements of Fla. Stat. §627.736(4)(b).
The Plaintiff is correct that the provisions of the Florida Statutes governing insurance become part of the insurance contract between the parties. Grant v. State Farm Fire & Casualty Co., 638 So.2d 936, 938 (Fla. 1994); Mia A. Higginbotham, D.C., P.A. v. United Automobile Ins. Co., 11 Fla. L. Weekly Supp. 748 (Broward Cty. Ct. 2004). As a result, when the Defendant failed to comply with the mandatory provisions of Fla. Stat. §627.736(4)(b), it breached its insurance contract with the insured. Accordingly, it is hereby
ORDERED AND ADJUDGED the Plaintiff’s Motion for Summary Judgment is GRANTED in part. A partial summary judgment is entered in favor of Plaintiff as to liability and at a minimum nominal damages on Count I of the Complaint.
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