12 Fla. L. Weekly Supp. 789a
Insurance — Personal injury protection — Coverage — Medical bills — Failure to authenticate within thirty days — Insurer’s attempts to toll time for authentication of medical bills through submission of explanation of benefits forms stating that bills were delayed were in clear violation of PIP statute — Since insurer was required to obtain peer review report as condition precedent to denial of payment for medical bills, insurer may not rely on report obtained after denial of payments — Partial summary judgment granted in favor of medical provider REVERSED at 14 Fla. L. Weekly Supp. 339a
OUTPATIENT PAIN & WELLNESS CENTER, (As assignee of Christine Scobee), Plaintiff, v. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Small Claims Division. Case No. 03-18710-CC. Division I. May 13, 2005. Charlotte Anderson, Judge. Counsel: Matthew D. Brumley, for Plaintiff. Randall Wainoris, for Defendant.
ORDER GRANTING THE PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on March 15, 2005 on the Plaintiff’s Motion for Partial Summary Judgment. Matthew D. Brumley, Esq. represented the Plaintiff and Randall Wainoris represented the Defendant. The court, being fully advised in the premises, makes the following findings of fact and law, and rules as follows:
1. The Plaintiff sought an award of partial summary judgment in regard to the following dates of service: April 25, 2003; April 28, 2003, April 30, 2003, May 5, 2003; May’s, 2003; May 28, 2003 and June 4, 2003.
2.The uncontested evidence illustrates that the Defendant’s sole basis for the its non-payment of the aforementioned medical bills was a Peer Review report, prepared by Howard Hochman, D.C. on July 18, 2003.
3. The Defendant/insurer refused to pay any amounts in regard to said medical bills, within the thirty day (30) authentication period afforded the insurer pursuant to Florida Statutes section 627.736(4)(b), and each respective authentication period expired prior to the existence of Dr. Hochman’s Peer Review report.
4. Rather than pay for these medical bills, the Defendant instead submitted correspondence and Explanation of Benefits forms to the Plaintiff which indicated only that the insurer’s payments of PIP benefits in regard to said medical bills were delayed.
5. The court finds, as a matter of law, that the Defendant’s attempts to toll the time in which it was to authenticate these medical bills were in clear violation of the Florida Motor Vehicle No-Fault statute. Ivey v. Allstate Ins Co., 774 So.2d 679, (Fla. 2000).
6. Further, Florida Statutes section 627.736(7)(a) provides that if an insurer bases their decision to refuse payment of a medical bill on a medical report prepared by a physician licensed under the same chapter as the treating physician, the statute clearly requires that the insurer first obtain said medical report, before it can suspend of withdraw the payment of PIP benefits.
7. Thus, in the present case, the court finds, as a matter of law, that the Defendant was required to obtain its Peer Review report as a condition precedent to denying the aforementioned medical bills, pursuant to Florida Statutes section 627.736(7)(a). United Automobile Ins. Co. v. Rodriguez, 808 So.2d 82 (Fla. 2001); United Automobile Ins. Co. v. Viles, 726 So.2d 320 (Fla. 3d DCA 1998); Milian v. United Auto Ins. Co., 12 Fla. L. Weekly Supp. 249a (Fla. Miami-Dade Cty. Ct. 2004); Pablo Mursuli, M.D. (a/a/o Thelma Orozco) v. United Automobile Ins. Co., 12 Fla. L. Weekly Supp. 95a (County Court for the Eleventh Judicial Circuit, September 30, 2004).
8. Under Florida law, since the Second District Court of Appeals has yet to address this issue, the court is bound to rely upon the Third District Court of Appeals decision in United Automobile Ins. Co. v. Viles, 726 So.2d 320 (Fla. 3d DCA 1998) pursuant to Conquest v. Auto-Owners Ins. Co., 637 So.2d 40, 42 (Fla. 2d DCA 1994), approved, 658 So.2d 928 (Fla. 1995) and Chapman v. Pinellas County, 423 So.2d 578, (Fla. 2d DCA 1982).
9. The court finds that, had the insurer adhered to Florida Statutes section 627.736(7)(a) and paid for these medical bills within the thirty day authentication period, as it was required to do, since it failed to possess its Peer Review at the time of its denials of payments, Florida Statutes section 627.736(4)(b) would have allowed the insurer to rely upon its subsequently obtained Peer Review report, to seek the recovery of any PIP benefits, which the insurer had paid. 10. Because the insurer failed to pay any PIP benefits in regard to any of the subject medical bills, the insurer is precluded from relying on Florida Statutes section 627.736(4)(b), and the Defendant is thus compelled to render payments for the aforementioned medical bills, due to its clear violations of Florida Statutes section 627.736(7)(a).
11. These tenets of the Florida Motor Vehicle No-Fault law provide the best means for allowing insureds to receive medical treatment, whilst providing insurers with a right to pursue a claim for any medical bills that were paid, which the insurer later deems unreasonable, unrelated or unnecessary, for it is the clear intent of the Florida Motor Vehicle No-Fault law, that insurers are to bear any risks involving the non-payment of medical bills, not their insureds.
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