12 Fla. L. Weekly Supp. 452a
Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — No error in finding insurer breached contract by failing to provide EOB for reduced or rejected claims without requiring medical provider to prove underlying treatment was reasonable and necessary
UNITED AUTOMOBILE INSURANCE COMPANY, Appellant, vs. R.J. TRAPANA, M.D., P.A., A Florida Corporation, a/a/o DUDLEY MABOUT, Appellee. Circuit Court, 17th Judicial Circuit (Appellate) in and for Broward County. Case No. 03-22360 CACE (05). February 14, 2005. Counsel: Russel M. Lazega, The Law Office of Russel Lazega, North Miami. Michael J. Neimand.
OPINION
(RICHARD D. EADE, J. ) THIS CAUSE comes before the Court upon Appellant’s, United Automobile Insurance Company (“United Automobile”), Appeal from the trial court’s Final Judgment rendered on November 25, 2003. [11 Fla. L. Weekly Supp. 251a] Having considered the appellate record, reviewed the relevant statutes and case law, and otherwise being advised in the premises, this Court dispenses with oral argument, and finds and decides as follows:
The instant action arises out of a PIP claim in which United Automobile was the insurer. Pursuant to Section 627.736(4)(b), Florida Statutes (2001), an insurer is required to provide claimants with an itemized specification of reduced or rejected claims detailing the reasons for non-payment or reduction. It is undisputed that United Automobile, after reducing or rejecting the claims of Appellee, R.J. Trapana, M.D., P.A. (“Trapana”), failed to furnish the itemized specification, despite a pre-suit request to do so. Trapana then brought suit in order to compel compliance with this request. The trial court entered Summary Judgment as to Count II, breach of contract, of Trapana’s Complaint against United Automobile for the failure to furnish said specification, in accordance with the statute.
United Automobile argues the trial court erred by finding it breached the contract by failing to provide the itemized specification since Trapana failed to prove the underlying treatment was reasonable and necessary. Derius v. Allstate Indemnity Company, 723 So.2d271 (Fla. 4th DCA 1998) and Cruz v. Union General Insurance, 586 So.2d 91 (Fla. 3d DCA 1991).
However, Derius and Cruz are not applicable to the instant case. Whereas, in the aforementioned cases, the claimants were required to prove the underlying treatments were reasonable and necessary since they were seeking relief from insurers based upon their denials of medical expenses after receiving medical examination reports, here, the matter involves a breach of contract claim based upon the insurer’s initial failure to provide specific information as required by statute.
Although, United Automobile has not provided this Court with a transcript of the proceedings below, the insurer’s obligation to provide an itemized specification is clear. §627.736(4)(b), Fla. Stat. On this issue, no genuine issues of material fact exist. United Automobile’s failure to provide the required specification resulted in a breach of its obligation, entitling Trapana to attorney’s fees and costs. §627.428(1), Fla. Stat.; Ivey v. Allstate Insurance Company, 774 So.2d 679 (Fla. 2001); Grant v. State Farm Fire & Cas. Co., 638 So.2d 936 (Fla. 1994). Accordingly, it is hereby
ORDERED AND ADJUDGED that the trial court’s Final Judgment rendered on November 25, 2003 is AFFIRMED. The matter of attorney’s fees and costs shall be determined by the trial court.
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