12 Fla. L. Weekly Supp. 396a
Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Form response letter that cites to various subsections of section 627.736, but does not explain which provisions apply, how medical provider violated statute, and what is needed to process claim is not legally sufficient EOB — Partial summary judgment entered in favor of provider on claim of entitlement to EOB and attorney’s fees
MANDELL CHIROPRACTIC AND REHABILITATION CENTRE, a Florida Corporation (assignee of James, Roosevelt), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 04-09672 COCE 53. September 29, 2004. William Herring, Judge. Counsel: Russel Lazega, The Law Office of Russel Lazega, North Miami. Leandro Lissa.
PARTIAL JUDGMENT FOR PLAINTIFF ON COUNTS I AND II OF PLAINTIFF’S COMPLAINT
This cause having been heard on August 30, 2004 on Final Hearing on Counts I and II, and the Court having received testimony, evidence, and legal argument at hearing, the Court finds in favor of Plaintiff as to Counts I and II of its complaint and enters Partial Judgment as follows:
FACTUAL BACKGROUND
1. This is a PIP insurance case.
2. On Apri1 25, 2003, Plaintiff filed a three count Complaint against Defendant.
3. Counts I and II claimed entitlement to an Itemized Specification of unpaid charges itemizing the reduced and unpaid charges and detailing the reasons for non-payment (commonly known as an explanation of benefits or “EOB”), the suit also claimed Entitlement to attorney’s fees and costs pursuant to Florida Statute §627.428 and Florida Statute §627.736 for the necessity of bringing an action to compel the insurer to comply with Florida Statute §627.736(4)(b) and provide the claimant with an intelligible written itemization of the reasons for non-payment.
4. Additionally, Plaintiff’s complaint contained a third count for breach of contract and damages seeking payment of unpaid insurance benefits, which is not being decided or addressed by this partial judgment as there remain fact issues to be tried by a jury. This partial judgment addresses only Plaintiff’s entitlement to the information requested and Plaintiff’s entitlement to recover from Defendant attorney’s fees and costs.
FINDING OF FACT
Based upon uncontrorted testimony presented by Dr. Alan Mandell at final hearing, the Court finds that:
1. Plaintiff timely submitted medical billing to Defendant for payment.
2. In response to each bill submission, Defendant issued essentially the same form response letter. The composite compilation of Defendant’s responses were admitted into evidence.
3. No evidence of any other response by Defendant was entered into evidence and Defendant represented at final hearing that the composite exhibit is its Explanation of Benefits and that its position is that the form letter satisfies the requirement of Florida Statute §627.736(4)(b).
Upon review of the evidence the court finds as follows:
1. Plaintiff is entitled to an itemized specification of unpaid charges intelligibly stating what charges are being paid and what charges are not being paid and explaining the reasons for non-payment such that the claimant can understand the basis for rejection and respond.
2. Defendant’s alleged explanation of benefits is not comprehensible and is woefully inadequate in terms of what Florida Statute §627.736(4)(b) requires, as Defendant’s purported itemized specification simply cites various sections of Florida Statute §627.736, but does not explain, if at all: 1) which provisions, if any, apply; 2) how the medical provider violated the statute; and 3) what is needed to process the claim.
3. The Court rejects Defendant’s argument that the composite itemized specification sent to Plaintiff is a legally sufficient itemized specification of unpaid charges (Explanation of Benefits). The document does not enlighten a medical provider as to how the claim should be properly billed nor does it explain why the bill was denied or reduced and what other information would be needed to process the claim.
4. Pursuant to Florida Statute §627.736(4)(b), an itemized specification requires a charge by charge specification, stating why the bill was denied or reduced, and what is specifically needed to process the claim.
5. Defendant has introduced no competent evidence that it has ever furnished Plaintiff with any other written explanation of denial.
6. The Court finds that not only is such an itemized specification required by Florida Statutes 627.736(4)(b), but it makes good sense on public policy grounds because the prompt exchange of information before suit is filed reduces the amount of litigation filed and allows claimants to resolve or correct problems with claims before suit is filed.
7. Providers armed with the information provided by an itemized specification can make informed decisions as to where they stand in relation to their submitted claims and resolve their issues with the insurer before needlessly involving the Court. Frivolous unnecessary litigation may thus be avoided. To rule otherwise would place a provider in an untenable “Catch-22” position of having to sue when it is in the dark, and then being faced with exposure for the imposition of Section 57.105(1), F.S., attorney’s fees when it learns that an insurance company properly reduced or denied a medical bill.
Accordingly, it is ordered and adjudged that
1. Partial Judgement be entered in favor of Plaintiff on Counts I and II of Plaintiff’s Complaint. Count III shall be tried by jury.
2. Plaintiff is entitled to attorney’s fees and costs related to Counts I and II, pursuant to Florida Statute §627.736(8) and Florida Statute §627.428 to be determined at a later date upon timely motion by Plaintiff.
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