12 Fla. L. Weekly Supp. 594b
Insurance — Personal injury protection — Claim form — Omission of license number — Insurer’s motion for final summary judgment asserting that it was not furnished with notice of loss due to medical provider’s failure to include license number in box 31 of HCFA forms is denied where insurer cannot reasonably assert that license number was needed to process or evaluate bills as it paid all bills submitted on identical forms prior to withdrawal of benefits based on independent medical examination, insurer never requested any information from provider regarding box 31 or suggested that it was in need of license number to be on notice of claim, and insurer cannot show any prejudice from omission of license number
WORLD HEALTH CHIROPRACTIC AND REHABILITATION, INC., as assignee of Elaine Haughton, Plaintiff, vs. NATIONWIDE PROPERTY AND CASUALTY INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 04-SC-1557. March 17, 2005. John R. Sloop, Judge. Counsel: Rutledge M. Bradford, Rutledge M. Bradford, P.A., Orlando. Scott Simmons, Lake Mary.
ORDER DENYING DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT
THIS MATTER having come before this Court on Defendant’s Motion for Final Summary Judgment and this Court having heard arguments of counsel and being otherwise fully advised in the premises, it is hereby,
ORDERED AND ADJUDGED:
1. Plaintiff filed this action for PIP benefits via an assignment of benefits from Elaine Haughton, against the Defendant for dates of service occurring in December of 2003, for an accident that had occurred on or about September 5, 2002.
3. The issue in this lawsuit is whether the Defendant properly terminated chiropractic benefits pursuant to an Independent Medical Examination done in October of 2002.
4. The Defendant has moved for Summary Disposition of this claim asserting that it is entitled to Judgment as a matter of law because the Plaintiff failed to include it’s license number in box 31 of the submitted HCFA’s. The Defendant contends that, accordingly, “the Defendant was not furnished with notice of the amount of a covered loss or medical bills and is therefore not responsible for payment.”
5. The Deposition of the Defendant’s corporate representative was taken on Monday, August 9, 2004 and revealed the following:
a. The automobile accident occurred on or about September 5, 2002.
b. The loss was reported on or about September 5, 2002.
c. Notice of the Loss was considered to have been timely made.
d. Nationwide Insurance received from the Plaintiff on October 14, 2002, bills for dates of service October 3, 4, 8 and 10, 2002, along with the appropriate supporting office notes.
e. These bills were submitted on HCFA’s and box 31 contained the typed words “signature on file” and the date of the submission, October 10, 2002.
f. The providers bills were paid in full without any additional request for information.
g. Likewise, the Defendant received additional bills on October 21, 2002 (for DOS 10/15 and 10/16) and on October 26, 2002 (for DOS October 21 and October 24, 2002). Each of these billings contained the identical information in box 31 as the previously submitted billings. Most of the billing submitted was paid in full and the withheld payments were not in any way related to box 31. Medical records were submitted with the bills.
h. On November 16, 2002, Nationwide terminated Chiropractic benefits for the assignor, Elaine Haughton, pursuant to an IME performed by Marvin Merritt, D.C.
i. Between December 20, 2003 and December 30, 2003, Ms. Haughton underwent 5 additional visits with Dr. Smith.
j. The billings for these visits were timely submitted and received by Nationwide on January 5, 2004. Box 31 on the HCFA’s was identical to the other bills previously submitted and medical records were provided.
k. Nationwide generated an explanation of benefits denying the bills solely on the basis of the IME. No other basis for denial was set forth.
l. Nationwide received a Notice of Intent to Initiate Litigation in April of 2004, seeking payment on bills that had not been paid in full prior to the IME cut-off, as well as bills incurred subsequent thereto.
m. In response to the Notice Letter, Nationwide paid all outstanding bills related to the treatment rendered prior to the IME and reasserted it’s refusal to pay those bills incurred following the IME, on the basis of the IME. No other reason was given for the denial of the bills.
6. The Plaintiff asserts that the Defendant is estopped from asserting the defense it now raises, in light of it’s acceptance and payment in full of charges contained on HCFA’s which it now contends did not put it on notice of the loss.
7. The license number of the provider does not provide any information that the carrier needs to evaluate, investigate or pay a claim.
8. Nationwide’s representative made it clear that the information contained or missing from box 31 had zero bearing on the review of the medical records submitted for payment. Nationwide never requested any information from the Provider regarding box 31 or suggested that it was in need of this information to be on notice of the claims.
9. Nationwide did not advise World Health Chiropractic, upon it’s initial submission of billings following the IME cut off that it could not process the bills because of information it needed from box 31. Nationwide did not put World Health Chiropractic on Notice, when it received their demand letter, that the reason for nonpayment hinged upon a technicality they were hiding behind. Had Nationwide advised World Health when it initially received it’s bills in January of 2004, via an explanation of benefits, that payment could not be considered due to the missing license number, World Health would have had sufficient opportunity to resubmit it’s billing timely. An affidavit by Dr. Sadat Smith outlining this was filed with the court.
10. The carrier cannot show any prejudice whatsoever from the conduct of the Plaintiff. The Defendant cannot reasonably assert that the license number was needed to process or evaluate any of the bills submitted, as it paid all the bills pre-IME cut off without it. Accordingly, the Defendant’s Motion for Final Summary Judgment is denied.
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