12 Fla. L. Weekly Supp. 671a
Insurance — Personal injury protection — Coverage — Medical bills — Late-submitted bill — Action by insured against PIP carrier for satisfaction of liens claimed by Medicare and health insurance carrier for medical bills originally submitted to and paid by health insurer and Medicare — Where bills were not submitted to PIP insurer within 30 days of rendition of treatment, bills are neither payable nor enforceable
NEOMIA WHITE, Plaintiff, vs. PROGRESSIVE CONSUMERS INSURANCE CO,., a foreign corporation, Defendant. County Court, 10th Judicial Circuit in and for Polk County. Case No. 53-2004CC-01800-WH. November 4, 2004. Steven L. Selph, Judge. Counsel: Sherri Scarborough, for Plaintiff. Scott W. Dutton, Haas, Dutton, Blackburn, Lewis & Longley, P.A., Tampa, for Defendant.
AFFIRMED. 13 Fla. L. Weekly Supp. 420a
SUMMARY JUDGMENT
THIS MATTER came on to be heard on October 22, 2004, on the Defendant’s, PROGRESSIVE CONSUMERS INSURANCE COMPANY (hereinafter “Progressive”), motion for summary judgment and after reviewing the file and considering argument of counsel, to include various citations of statutory and case law it is ORDERED AND ADJUDGED THAT SUMMARY JUDGMENT IS GRANTED in favor of the Defendant on the following grounds:
1. This case involves a dispute over personal injury protection benefits.
2. The Plaintiff, Neomia White, claims that she was injured in a motor vehicle accident that occurred on or about November of 1999.
3. As a result of the subject accident, the Plaintiff claims to have incurred certain medical expenses that are not specified in Plaintiff’s Complaint but for purposes of summary judgment, that issue is not disputed.
4. The Defendant, Progressive, has asserted by affidavit that any and all bills or expenses submitted to Progressive within 30 days of services being as required by Section 627.736(5)(c)(1) have been or were paid on a timely basis. No bills that were submitted to Progressive by providers were denied or reduced by them.
5. The Plaintiff does not factually dispute that point; rather, the Plaintiff argues that the bills in dispute were initially submitted to and paid by the Plaintiff’s health insurer, Blue Cross/Blue Shield, or Medicare, who later claimed liens against the Plaintiff’s bodily injury recovery arising out of her November 1999 accident.
6. The Plaintiff notified Defendant Progressive/PIP Insurer of the liens and Defendant Progressive refused to pay.
7. The Plaintiff paid the liens out of her bodily injury recovery, and notified the Defendant Progressive/PIP Insurer of the Plaintiff’s payment of the liens in 2003 in a subsection 11 presuit demand letter, and requested reimbursement.
8. In response to the Plaintiff’s request for reimbursement, Defendant Progressive claimed it was not required to pay the bills or that they were unenforceable citing to the Court the legislative history and case law underpinning the 1998 version of section 627.736(5)(c)(1) that provides in pertinent part (with emphasis added):
(c) 1. With respect to any treatment or service, other than medical services billed by a hospital or other provider for emergency services as defined in s. 395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 30 days before the postmark date of the statement . . . The injured party is not liable for, and the provider shall not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable.
9. It is undisputed by the Plaintiff that there are no bills that were submitted to Progressive by the providers that were not paid within the 30 days as required by the statute.
10. Rather, the Plaintiff asserts that because the provider charges were submitted to and paid by Blue Cross/Blue Shield and Medicare, who claimed a lien against the Plaintiff’s bodily injury recovery, that somehow that scenario alters or disallows the Defendant the protection of the 30 day statutory mandate for the submission of bills found in the PIP statute.
11. The Plaintiff further asserts that the federal statutory lien rights found within the Medicare statute preempt the insurer’s statutory protections of the Florida PIP statute.
12. The Defendant responds that there are many reasons, aside from the 30 day requirement of the statute, that PIP bills are to be submitted promptly to the PIP insurer. That includes the fact that generally speaking, PIP bills should be paid within 30 days of submission, unless there has been statutory or contractual non-compliance, or the insurer has “reasonable proof” why they should not pay.
13. As the supreme court said in United Automobile Insurance Co. v. Rodriguez, 808 So.2d 82 (Fla. 2001), the legislative intent of section 627.736(4) is to promote prompt resolution of PIP claims.
14. The court in United Automobile cited the principle that under the PIP statute the insurer has thirty days in which to verify a claim, and the burden is clearly on the insurer to authenticate the claim within the statutory period.
15. Thus, a PIP insurer, like Defendant, is given thirty days to investigate and to either pay the claim or discover the facts that warrant a refusal to pay; if it does not do so, then the claim is overdue and the statutory penalties for failing to pay the claim timely (interest and fees) are due.
16. Here the Defendant points out that because the providers failed to promptly submit the bills to them within the 30 days as required by the statute, they were not afforded the ability to investigate the claims on a timely basis by the use of examinations under oath, independent medical examinations, peer reviews, etc.
17. The Court finds that the federal statutory lien rights for Medicare under 42 USC Section 1395 apply to PIP benefits but only if the right to such benefits have been perfected by timely submission of PIP claim.
18. The Defendant further points out that plainly the bills are not payable to anyone, or per the PIP statute is not enforceable against anyone, because of the violation of the 30 days for submission by the provider as required by the statute, and that the federal statute and health insurer’s lien rights cannot resurrect the statutorily foreclosed duty to pay.
19. This Court agrees with the Defendant’s position that because of the providers’ failure to submit the bills to the PIP insurer within 30 days of being rendered, they are neither payable nor enforceable.
20. SUMMARY JUDGMENT IS GRANTED in favor of the Defendant, and the Defendant shall go hence without day. The Court retains jurisdiction to determine attorney’s fees and taxable costs.
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