12 Fla. L. Weekly Supp. 33a
Insurance — Personal injury protection — Coverage — Unreasonable, unrelated or unnecessary medical expenses — Where insurer did not raise affirmative defense of excessiveness of amounts billed or present any evidence that individual amounts billed were excessive, medical provider met burden of proof on reasonableness and necessity of services through testimony of treating physician and was not required to present specific expert testimony addressing reasonableness of amounts billed — On cross-claim, summary judgment against third-party provider of MRI and CT-scan is reversed and remanded for trial on reasonableness and necessity of tests
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Appellant/Cross Appellee, v. MULTICARE MEDICAL CENTER, INC., and PHYSICIANS ASSOCIATES GROUP, INC., as assignees of Reina Fernandez, Appellees, and ADVANCED DIAGNOSTIC TESTING INC., as assignee of Reina Fernandez, Cross-Appellant. Circuit Court, 11th Judicial Circuit (Appellate) in and for Dade County. Case No. 03-349-AP. L.C. Case No. 01-4581-CC-26. October 5, 2004. An appeal from the County Court for Miami-Dade County, Judge Ellen Sue Venzer. Counsel: Nancy W. Gregoire, Bunnell, Woulfe, Kirschbaum, Keller, McIntyre & Gregoire, for Appellant/Cross-Appellee. Charles L. Vaccaro, Lidsky, Vaccaro & Montes, for Appellee/Cross-Appellant.
(Before KORVICK, MUIR and HUBBART, JJ.)
(Muir, Judge.) This is an appeal from a final judgment entered on a jury verdict in favor of medical providers that had received assignments of benefits from Reina Fernandez, an insured of the appellant, State Farm. There is also a cross-appeal from a summary judgment entered in favor of State Farm denying payment for services provided by a separate medical provider Advanced Diagnostic Testing. Advanced Diagnostic performed an MRI (for $1,850) and a CT-Scan (for $1,250) on behalf of the insured.
It is clear from the arguments presented by State Farm that a denial of benefits was based on the excessive number of therapy visits, two follow up medical examinations, as well as referrals of the insured for a second opinion, which resulted in a total claim of $7,088 for medical examinations, therapy and x-rays by Multicare. State Farm paid a portion of Multicare’s bills, specifically a medical examination on March 2, 1999, and the therapy that took place from March 5, 1999, through March 15, 1999. The Multicare bills rejected by State Farm were a follow-up examination on March 25, 1999, a final examination on May 26, 1999, and therapy that took place from March 16, 1999 through May 25, 1999.
As to the referral for a second opinion, Dr. Ronchetta, the insured’s treating doctor, referred the insured for orthopedic consultation with PAG (Physicians Associates Group) which billed for services on March 29, 1999, April 19, 1999, and May 17, 1999.
Based on the evidence presented by the plaintiffs, the jury accepted in part the testimony of Dr. Daniel Ronchetta, and found amounts due as reasonable for both Multicare ($3,000, less than half the amount billed) and PAG ($575, which is also a fraction of the amounts billed) that were reduced to 80 percent, i.e., $2,400 plus prejudgment interest of $891.66, and $460, plus prejudgment interest of $175.63.
The issue presented on the main appeal is whether the plaintiffs met their burden of proof in testifying that the services billed were reasonable and necessary, without specific expert testimony addressing the costs.
In its answer, State Farm denied the plaintiffs’ allegation that it had breached its contract with the insured, and that the bills at issue were reasonable, necessary or for injuries related to a crash for which there was coverage.
No affirmative defense raised the issue that if the medical services were found to be reasonable and necessary, the amounts billed for them were excessive.
There was testimony that the services were necessary and reasonable, but no specifics as to the amounts charged for particular services. State Farm moved for a directed verdict and challenges the award of medical expenses to the plaintiff providers.
State Farm sought a judgment in its favor, asserting that Multicare and PAG did not sustain its burden of proof; however, it appears that custom and usage does not require that an expert on medical service fees be called, or that each provider comment on its bills as reasonable in amount in order to establish a claim for unpaid medical bills pursuant to the PIP statute.
Generally, to establish a reasonable amount of compensation for an expert’s services, the expert providing or supervising those services testifies as to reasonableness and necessity. No corroborating evidence from a separate expert on compensation is required, except to establish attorneys’ fees (other than family law matters, as no corroborating expert on attorneys’ fees is required by recent reforms in the area of family law.)
In cases when the amount of medical services billed is in question, there could be a requirement that separate proof of “customary charges” in the medical industry be offered in every case to prove the compensation was warranted; however, this requirement is best left for legislative consideration. Under current standard jury instructions, the question of reasonableness of medical expenses is a question of fact to be established by expert witnesses, or by a plaintiff’s testimony, to be resolved if contested by a jury. See Albertson’s, Inc. v. Brady., 475 So.2d 986 (Fla. 2d DCA 1985); East West Karate Association, Inc. v. Riquelme, 638 So. 2d 605 (Fla. 4th DCA 1994).
Unlike cases for attorneys’ fees, there is no requirement that a finding of entitlement to fees for reasonable and necessary medical services be followed by a finding of reasonable hours and reasonable rates. The position of State Farm is inconsistent with current practice and procedure. See State Farm Mutual Automobile Insurance Co. v. Universal Medical Center of South Florida, Inc., 2004 WL 57442 (Fla. 3d DCA Mar. 17, 2004) [29 Fla. L. Weekly D652e], commenting that a court may look to the custom and usage in the industry to support a decision.
In this case, as in most personal injury cases, a treating doctor testified as to reasonableness and necessity of the services rendered. The bills were introduced into evidence. To oppose the providers’ evidence, the defense called an independent medical examiner, who disputed the need for any more than a minimum of treatment and the total amounts billed. There was no defense testimony that the individual amounts billed for services were excessive.
The questions for the jury are stated on the jury verdict.
Did State Farm breach its contract by failing to pay medical expenses at issue in this case which were reasonable, necessary, and causally related to the motor vehicle accident . . . ?
What is the dollar amount of all reasonable and necessary medical expenses that are causally related to the accident . . . ?
The trial judge instructed the jury that State Farm Mutual Automobile Insurance Company is responsible for payment of all reasonable expense for necessary medical services, consistent with §627.736, Florida Statutes.
In this case, the jury weighed the conflicts in the expert witnesses’ testimony, considered the bills in evidence, and determined the issue of reasonableness.
State Farm suspects that perhaps the insured received a higher level of medical care, with the result that her PIP benefits were exhausted, then services were stopped. Laws that address such abuse should be enforced; however, there is no evidence in the record that the plaintiff or the providers here are involved in fraudulent medical practices.
As to the cross-claim by Advanced, we agree that a trial on the issues of reasonableness and necessity for the CT Scan and the MRI is required. The case of Professional Consulting Service, Inc. v. Hartford Life and Accident Insurance Company, 849 So. 2d 446 (Fla. 2d DCA 2003) controls our view of the issues raised. Accordingly, the partial summary judgment dated February 20, 2003 against Advanced, and the final judgment against Advanced are reversed, and its cause remanded for a trial on the remaining issues.
The final judgment on the jury’s verdict is affirmed as to Multicare and PAG.
Appellate attorneys’ fees and costs are awarded to Multicare and PAG, on remand, to be determined as to amount by the trial judge. The appellee Advance must prevail at trial in order to recover its appellate fees. See Tench v. American Reliance Ins. Co., 671 So. 2d 801, 802 (Fla. 3d DCA 1996).
Affirmed in part and reversed in part.
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