13 Fla. L. Weekly Supp. 1100a
Insurance — Personal injury protection — Explanation of benefits — Non-compliance letter quoting large portions of PIP statute does not satisfy requirement for EOB — Because statutory requirement that insurer furnish claimant with EOB became part of insurance contract, breach of contract action is proper where insurer has failed to provide EOB to medical provider/assignee — Attorney’s fees and costs awarded to provider
DADE INJURY REHABILITATION CENTER, a Florida Corporation (assignee of Alexis, Dennedyta), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-03260 COSO 60. August 14, 2006. Sharon Zeller, Judge. Counsel: Russel Lazega, Law Office of Russel Lazega, North Miami, for Plaintiff. Monica Barnes, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT I COMPLAINT (BREACH OF CONTRACT SEEKING ITEMIZED SPECIFICATION OF UNPAID CHARGES/EOB)
THIS CAUSE came before the Court on August 14, 2006, for hearing on Plaintiff’s Motion for Summary Judgment (Count I — Breach of Contract — seeking itemized specification of unpaid charges), and the Court’s having reviewed the Motion and entire Court file; reviewed the relevant legal authorities; heard argument, and been sufficiently advised in the premises the Court finds as follows:
Background: Thisis a P.I.P. case. Count I of Plaintiff’s complaint seeks claim information pursuant to Florida Statute s. 627.736(4)(b) — specifically, an itemized specification of unpaid charges (also known as an Explanation of Benefits or EOB). Alleging that it did not receive the required statement of the reasons for non-payment of its charges from Defendant, (and having not received a response to Plaintiff’s pre-suit demand letter requesting the information) the Plaintiff filed its Complaint against Defendant for Breach of Contract seeking an itemized specification of unpaid charges/Explanation of Benefits itemizing the charges received by Defendant from Plaintiff and detailing the reasons for non-payment. The gist of the Count at issue (Count I is that the Defendant failed to provide the explanation of benefits required by Florida Statute §627.736(4)(b).
Defendant responds that it complied with the provisions of Florida Statute §627.736(4)(b) in the form of a “non-compliance letter” quoting large portions of the P.I.P. statute sent to Plaintiff.
CONCLUSIONS OF LAW
Does Defendant’s “Non-Compliance Letter”Constitute an Itemized Specification per F.S s.627.736(4)(b)?
A number of other Broward County judges have addressed this issue and consistently ruled that the letter in question is NOT sufficient.
The court agrees with the decision in Fidel S. Goldson D.C., P.A. v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 161 (County Court, Broward County, Judge Robert W. Lee 2004) that “Under no reading of the word “specification” does the language of the insured’s letters meet the requirements of the statute. Rather than “explicitly stating” the reason for the denial, the insured’s response to the claim does nothing more than confuse the matter even further.”
MAY PLAINTIFF MAINTAIN AN ACTION FOR BREACH OF CONTRACT FOR FAILURE TO PROVIDE AN ITEMIZED SPECIFICATION OF CHARGES/EOB?
The appellate division of this circuit has twice affirmed that an assignee medical provider may maintain an action for breach of contract for failure to furnish an Explanation of Benefits. United Auto. Ins. Co. v. R.J. Trapana, M.D., P.A. (Decision of the Honorable Richard Eade) Circuit Court, Broward County (Appellate) 12 Fla. L. Weekly Supp. 452a (2005) Review Denied by 4th District Court of Appeal; United Auto. Ins. Co. v. Stat Technologies, Inc. (Unpublished Appellate Decision of Judge John Luzzo, Circuit Court, Broward County 2005). This court agrees that the provisions of the Florida Statutes governing insurance become part of the insurance contract between the parties, Grant v. State Farm Fire & Casualty Co., 638 So.2d 936, 938 (Fla. 1994); Mia A. Higginbotham, D.C., P.A. v. United Automobile Ins. Co., 11 Fla. L. Weekly Supp. 748e (Broward Cty. Ct. 2004), and that accordingly, the provision of Florida Statute s. 627.736(4)(b) requiring the insurer to furnish the claimant with an itemized specification of unpaid charges became part of the contract and a breach of contract action is proper. See Id.; See also, Goldson v. United Auto. Ins. Co. (Decision of Judge Robert Lee, Broward County case # 03-7459 COSO 62) [12 Fla. L. Weekly Supp. 161b]; STAT Technologies, Inc. v. United Auto. Ins. Co. (Decision of Judge Lee Jay Seidman, Broward County Case 02-01929 COSO 62); All Care Health & Wellness (Decision of Judge Sharon Zeller, Broward County Case 03-3115 COSO 60). As a result, when the Defendant failed to comply with the mandatory provisions of Fla. Stat. §627.736(4)(b), it breached its insurance contract with the insured. Accordingly, it is hereby
ORDERED AND ADJUDGED the Plaintiff’s Motion for Summary Judgment is GRANTED. Summary judgment is entered in favor as to Count I of the Complaint. Plaintiff is the prevailing party as to this count and pursuant to Florida Statute 627.428, Plaintiff is entitled to recover from Defendant attorney’s fees and costs as to Count I in an amount to be determined at a later hearing, for which, the court reserves jurisdiction.
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