12 Fla. L. Weekly Supp. 969a
Insurance — Personal injury protection — Coverage — Medical expenses — Unreasonable, unrelated or unnecessary treatment — Failure to obtain medical report within 30 days — Insurer cannot defend suit for denial of benefits on grounds of reasonableness, necessity or relatedness where peer review was not obtained until after bills became due and owing
Editor’s note: Per Curiam Affirmed by circuit court. Affirmed by district court on second-tier certiorari review at 34 Fla. L. Weekly D58a (Granada Ins. Co. v. Cereceda)
MARK A. CERECEDA, D.C., P.A. A/A/O MANUEL ESCALAR, Plaintiff, vs. GRANADA INSURANCE COMPANY, Defendant(s). County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 02-28922 CC23 (04). July 12, 2005. Jacqueline Schwartz, Judge. Counsel: Craig H. Blinderman and Mary-Margaret Warren, Mrejen Blinderman, P.L., Ft. Lauderdale, for Plaintiff. Carlos Diaz-Padron and Jeffrey F. Antell, for Defendant.
ORDER GRANTING PLAINTIFF FINAL SUMMARY JUDGMENT
THIS MATTER, having come before the Court on March 8, 2005 on Plaintiff’s Motion for Final Summary Judgment and the Court having reviewed the motion and having heard the argument of counsel,
The Court makes the following findings of undisputed fact:
1. Plaintiff, Mark A. Cereceda, D.C., P.A. (“Plaintiff”) submitted bills to Defendant, Granada Insurance Company (“Defendant”) for medical services rendered to the claimant, Manuel Escalar (“claimant”) for dates of service April 30, 2002 through September 3, 2002.
2. Plaintiff’s total bills amount to $9,802.00 ($11,315.00 x 80%).
3. All of the bills at issue were received by Defendant on or before September 9, 2002.
4. Defendant conducted a peer review of Plaintiff’s bills and medical records on October 21, 2002. This peer review was conducted by Jeffrey S. Senter, D.C. Affidavits of Dr. Senter were filed on October 4, 2004 and November 15, 2004.
5. Jeffrey S. Senter, D.C. opined that certain services (CPT codes in the amount of $2,768.00) were reasonable, necessary, and related to the subjectmotor vehicle accident, and that the remainder of the submitted bills were not reasonable, related, or medically necessary.
6. On November 27, 2002 Plaintiff filed the instant action. On December 2, 2002, after suit was filed, the Defendant attempted to make payment in the amount of $2,740.00 as full and final payment for all outstanding bills at issue. Plaintiff returned said payment to Defendant.
7. Plaintiff filed an affidavit of treating physician, Mark A. Cereceda, D.C. on August 10, 2004 stating that all of the medical services at issue were reasonable, medically necessary and related to the subject motor vehicle accident. Dr. Cereceda further attested that the charges for the medical services were reasonable and customary.
8. On November 17, 2004, Plaintiff and Defendant stipulated that certain medical services (CPT codes) were reasonable, medically necessary and related to the subject motor vehicle accident.
The Court makes the following conclusions of law:
1. The court finds the stipulated services in the amount of $2,768.00 to be reasonable, medically necessary and related to the subject automobile accident andgrants Plaintiff partial summary judgment as to these medical services. The Defendant is ordered to pay Plaintiff reasonable attorney’s fees and taxable costs pursuant to F.S.§627.428 for securing these benefits. A&L Medical Images, Inc. and Reginald Bottari, D.C., P.A.(Osvaldo C. Fernandez) v. United Automobile Insurance Company, Case No.: 02-00078 SP 26 (03): 02-3721 SP 26 (02) (consolidated cases) (Order of Honorable CristinaPereyra-Shuminer dated September 24, 2003).
2. The Courtfurther finds that the Plaintiff is entitled to a final summary judgment on all the bills at issue since all of these bills were due and owing prior to the peer review conducted by Jeffrey S. Senter, D.C. on October 21, 2002. The Court finds that for an insurance carrier to defend a suit for reduction, withdrawal, or denial of further payments on the grounds of reasonableness, necessity or relationship by use of a medical report (such as a peer review), that obtaining such a report is a condition precedent pursuant to F.S.§627.736(7)(a). United Auto. Ins. Co. v. Viles, 726 So.2d 320 (Fla. 3rd DCA 1999), Optima Health & Rehab (Ricardo Abreu) v. United Auto Ins. Co., 11 Fla. L. Weekly Supp. 146a(Fla. Miami-Dade County 2003) and United Auto. Ins. Co. v. Prof’l Med. Group, Sol Angel Hurtardo, 11 Fla. L. Weekly Supp. 877a (Fla. 11th Cir. App. 2004).
3. The Defendant is hereby ordered to pay Plaintiff reasonable attorney’s fees and taxable costs pursuant to F.S.§627.428 for securing these additional benefits.
It is hereby ORDERED and ADJUDGED that the Plaintiff’s Motion for Final Summary Judgment is granted in the amount of $9,802.00 plus applicable interest in the amount of $1,248.72 for a total judgment of in the amount of $11,050.72 for which let execution issue forthwith.
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