13 Fla. L. Weekly Supp. 1009b
Insurance — Personal injury protection — Explanation of benefits — Failure to provide — Insurer breached contract by failing to provide EOB requested by insured in pre-suit demand letter — No merit to argument that insurer was relieved of continuing obligation to provide EOB where benefits were exhausted prior to demand for EOB
DAVID SALINAS, Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 05-7481 COSO 62. July 27, 2006. Sharon L. Zeller, Judge. Counsel: Joshua Meadow and Russel Lazega, Law Office of Russel Lazega, North Miami, for Plaintiff. Rashad H. El-Amin, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT I
This action came before the Court on Plaintiff’s Motion For Summary Judgment as to Count I of Plaintiff’s Complaint, and the Court having heard argument of counsel, and being otherwise advised in the premises, it is hereupon ordered and adjudged as follows:Factual Findings
1. Plaintiff was treated by multiple health care providers for injuries sustained in an accident on April 5, 2004.
2. Plaintiff sent a pre-suit demand letter to the Defendant pursuant to FS § 627.736(11) on July 29, 2005, which included revocations of assignments of benefits, specifically requesting an “explanation of benefits” be provided to the Plaintiff.
3. Defendant did not provide itemized specifications/explanation of benefits to the Plaintiff in response to the Demand Letter, or make any response at all.
4. Defendant contends that because it exhausted benefits prior to the pre-suit demand, it was not required to furnish the Plaintiff with an itemized specification/explanation of benefits as defined by FS § 627.736(4)(b) when requested, even after revocations of assignments of benefits were provided to the Defendant.
Conclusions of Law
This Court finds no merit in the Defendant’s argument that it is relieved of a continuing obligation to provide an itemized specification/explanation of benefits where benefits were exhausted prior to the pre-suit demand. Quite simply, the Plaintiff, in this case the insured himself, is entitled to an itemized specification/explanation of benefits for all benefits paid on his behalf, or of any reductions, denials or non-payment of his claim. Even if an explanation has been furnished to the health care provider, the insured always has a stake in the claim and the right to the information. The statute is clear and the policy makes good sense in avoiding needless litigation — the insurer is to specify “each item that the insurer reduced, omitted or declined to pay.”
This Court finds guidance in Judge Richard Eade’s decision in United Automobile Insurance Company vs. R.J. Trapana, M.D., P.A. (a/a/o Dudley Mabout), Circuit Court, 17th Judicial Circuit (Appellate) in and for Broward County, Case No. 03-222360 CACE 05 (February 14, 2005) reported at 12 Fla. L. Weekly Supp. 452a, where, as in this case, the Plaintiff brought an action for breach of contract where the insurer failed to provide an itemized specification pursuant to FS §627.736(4)(b) in response to a pre-suit demand for same. Judge Eade ruled “United Automobile’s failure to provide the required specification resulted in a breach of its obligation, entitling Trapana to attorney’s fees and costs.”
Accordingly, Partial Summary Judgment is entered for the Plaintiff, and Plaintiff is entitled to fees and costs pursuant to FS §627.428 to be determined at a later date.
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