13 Fla. L. Weekly Supp. 1110a
Insurance — Personal injury protection — Declaratory judgment — Insurer’s obligation to provide policy, declarations page and/or PIP log on presuit request from medical provider/assignee — Summary judgment entered against insurer that failed to provide policy, declarations page and PIP log requested by provider prior to suitReversed and remanded at 16 Fla. L. Weekly Supp. 230a
FLORIDA EMERGENCY PHYSICIANS KANG & ASSOCIATES, M.D., P.A. As assignee of Jose Quinones, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit of Seminole County. Case No. 06-SC-000429. August 25, 2006. John Sloop, Judge. Counsel: Kevin B. Weiss, Weiss Legal Group, P.A., Maitland. John Morrow, Orlando.
ORDER GRANTING PLAINTIFF’S MOTION FOR FINAL SUMMARY JUDGMENT AS TO COUNT II OF PLAINTIFF’S COMPLAINT
THIS MATTER having come before this Court on Plaintiff’s Motion for Final Summary Judgment asto Count II of its Complaint and this Court having heard arguments of counsel and being otherwise fully advised in the premises, finds as follows:
Facts
1. This is a claim for a declaratory judgment and for PIP benefits arising out of a motor vehicle collision that occurred on or about September 7, 2005.
2. The Plaintiff in this matter Florida Emergency Physicians Kang & Associates, M.D., P.A. (hereinafter, “FEP”), accepted an assignment of benefits from Jose Quinones.
3. The Plaintiff submitted its bill for care and treatment of the insured to the Defendant and the bill went unpaid.
4. Thereafter, on December 20, 2005, a Notice of Intent to Initiate Litigation was sent to the Defendant’s designated “designee” pursuant to Florida law and was signed for by the Defendant. Included in the Notice package was a request for a copy of the policy, declarations page and PIP log, as provided for in Florida statutes.
5. The Defendant responded to Plaintiff’s demand by indicating that the PIP benefits were exhausted. The Defendant provided a copy of the patient’s policy and an insurance disclosure statement. The Defendant also sent FEP a check listing showing payments to medical providers that it made under Mr. Quinones’s PIP policy. However, the check listing did not provide FEP with any information regarding the date State Farm received the medical bills or whether those bills were paid at 80% or 100%.
6. On January 23, 2006, FEP, through its attorney, sent State Farm a letter acknowledging its receipt of the check listing and specifically requesting “a copy of the PIP log showing the dates bills were received.” The letter also stated “Please forward this information to avoid litigation.”
7. State Farm did not respond to the January 23, 2006 letter and thus FEP was not able to obtain the information it sought regarding State Farm’s receipt of the medical bills. This follow-up request by Plaintiff and Defendant’s failure to respond is the crux of this Court’s ruling.
8. On February 8, 2006, the Plaintiff filed a Complaint alleging breach of contract and seeking declaratory relief.
9. The Defendant’s failure to comply with FEP’s presuit requests for information necessitated the filing of this lawsuit.
10. Summary Judgment is proper where there exists no genuine issue of material fact and the Plaintiff is entitled to Judgment as a Matter of Law.
Analysis
The court is well aware of the multitude of complex issues involving PIP. Exhaustion of benefits and priority of payments continue to be a source of much confusion. A plaintiff must be vigilant in ascertaining whether a deductible truly applies; whether it has been correctly applied to the bills in the order in which they were received; where its claims rest in relation to other claims submitted; whether benefits remain, and, if so, what bills have been submitted that are entitled to payment.
The nature of litigation in this area is such that a Plaintiff may well end up spinning its wheels needlessly if benefits have in fact been paid out properly and in full. In short, the only method of obtaining a verifiable objective answer to these issues is to obtain a PIP payout sheet; declarations page and a copy of the policy in effect. By requesting this information pre-suit, the Plaintiff is attempting to assess whether the filing of a lawsuit is warranted.
In this case, the Plaintiff waited for the insurance information it had requested from State Farm before resorting to filing suit. The Defendant had the ability to provide this information. Sometimes information relayed by adjusters pre-suit has turned out to be incorrect once suit has been filed so the examination of actual PIP logs and declarations pages is needed to determine whether the bills were in fact subject to a deductible; whether benefits have in fact been exhausted; and the policy is needed to review the actual language that determines, and, with respect to out of state coverages, whether the policy contains language that would afford coverage in the state of Florida.
The law regarding a medical provider’s right to receive insurance documentation presuit has been resolved in the Eighteenth Judicial Circuit. Recently, in New Hampshire Indemnity Insurance Co. vs. Rural Metro Ambulance a/a/o William Zaniboni [13 Fla. L. Weekly Supp. 573a],Case No. 04-72-AP (18th Judicial Cir., Appellate Division, November 18, 2005), a three judge circuit appellate panel found that Rural Metro “was entitled to the information and documentation requested pursuant to the assignment of benefits received from [an insured].” The court agreed with Rural Metro that it has a right to determine, pre suit, what claims have been made and when; if any claims have been paid or denied; whether the deductible has been met; and, if not, how much remains; and whether benefits have truly been exhausted. The court went on to say:
Whether such information is complied in a PIP log or some other data compilation format is immaterial. For these same reasons, RMA has a right to a copy of the insurance policy and declarations page. Although a requirement to provide such information may not be expressly stated in Section 627.736, Florida Statutes, this Court finds that the provision of such information is essential to RMA’s ability todetermine its status as a claimant and makes eminently good common sense. Furthermore, the Court finds that the provision of such information by an insurer to an insured, or its assignee, is consistent with the purpose of the no-fault statutory scheme, to wit: “to ‘provide swift and virtually automatic payment so that the injured insured may get on with his life without undue financial interruption.’ ” See Allstate v. Ivey Ins. Co., 774 So.2d 679, 683-684 (Fla.2000) (quoting Government Employees Ins. Co. v. Gonzalez, 512 So.2d 269, 271 (Fla. 3d DCA 1987)). To hold otherwise would place providers in the untenable position of having to rely solely upon the explanation of the insurer without corresponding proof.
Moreover, this Court finds that RMA was entitled to the information and documentation requested pursuant to the assignment of benefits received from Zaniboni, which NHI did not contest below. Surely, Zaniboni had a contractual right to receive a copy of his insurance policy and declarations page any time he saw fit. Likewise, Zaniboni wasentitled to know what claims had been made and paid; as well as the benefits remaining, if any, at a given point in time. By executing an assignment of benefits, RMA obtained all of the rights and benefits of Zaniboni under the policy including the right to obtain the requested documentation. See State Farm Fire and Casualty Co. v. Ray, 556 So. 2d 811, 812 (Fla. 5th DCA 1990) (citing Fla. Jur.2d, Assignments § 1 (1978) in defining an assignment as “. . . the act by which one person transfers to another, or causes to vest in another, his right of property or interest therein.”).” [Emphasis added.]
Other recent appellate opinions from this jurisdiction have followed Zaniboni. See Progressive Express Insurance Co. v. Physical Medicine Group, a/a/o Audra Isaacson, Appeal No. 05-13-AP (18th Cir. Ct. Appellate Division May 11, 2006) and Florida Emergency Physicians a/a/o William Eve v. American Vehicle Insurance Co., Appeal No. 05-60-AP, (18th Judicial Circuit Ct. Appellate Division April 21, 2006). This Court has issued numerous rulings that an insured may file a declaratory judgment action in order to obtain insurance documentation.1 Other judges around the State of Florida have issued similar opinions.2
It is therefore ORDERED AND ADJUDGED that:
1. Plaintiff’s Motion for Final Summary Judgment as to Count II of its Complaint is HEREBY GRANTED.
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1See e.g., Kelly Purvin v. Progressive Express Insurance Company, Case No.: 04-SC-3285 (Seminole Cty. Ct. February 8, 2005) [12 Fla. L. Weekly Supp. 1104c] (summary judgment was granted to the Plaintiff based on a pre-suit request for insurance documentation that was not provided); Florida Emergency Physicians Kang & Associates, M.D., P.A. a/a/o Dean Walker vs. Nationwide Mutual Fire Ins. Co., 12 Fla. L. Weekly Supp. 592a (Fla. Seminole Cty. Ct. 2005); Florida Emergency Physicians a/a/o Vernon Brown vs. Nationwide Property & Casualty Ins. Co., 12 Fla. L. Weekly Supp. 505a (Fla. Seminole Cty. Ct. 2005); Florida Emergency Physicians Kang & Associates, M.D., P.A. a/a/o William Eve vs. American Vehicle Insurance Co., 12 Fla. L. Weekly Supp. 593a (Fla. Seminole Cty. 2005); The Stand-Up MRI of Orlando, P.A. a/a/o Francela Henry vs. OMHI Ins. Co., Case No. 04-SC-815 (Seminole Cty. Ct., January 23, 2006) [13 Fla. L. Weekly Supp. 396a]; Gary H. Weiss, D.C., DABFE a/a/o Daisy Rivera vs. Mercury Ins. Co. of FL, Case No. 05-CC-509 (Seminole Cty. Ct., January 23, 2006).
2Other trial level cases involving successful declaratory judgment actions for insurance documentation/information from PIP carriers include Rural Metro Ambulance (Aletha Bryant) v. Liberty Mutual Insurance Company, 11 Fla. L. Weekly Supp. 583a (Orange Cty. Ct. 2004) (Judge Leon Cheek III); Tallahassee MRI, P.A. (Jacques Amilcar) v. Progressive Auto Pro Insurance Company, 11 Fla. L. Weekly Supp. 69a (17th Jud. Cir. 2003) (Judge Steven Deluca); Marcus Laws vs. Florida Automobile Joint Underwriting, 12 Fla. L. Weekly Supp. 566a (Fla. Duval Cty. 2005); Primary Care Medical Group a/a/o Bermudez Eliczer vs. United Automobile Ins. Co., 12 Fla. L. Weekly Supp. 493a (Fla. Broward Cty. Ct. 2005); Greater Chiropractic Center Corp. a/a/o Gurvinder Ghandi vs. Alpha Property & Casualty Insurance Company, Case No. 05-SC-3559 (Orange Cty. Ct., November 4, 2005) [13 Fla. L. Weekly Supp. 352b]; Florida Emergency Physicians, Kang & Associates, M.D., P.A., a/a/o Darrell Mixon vs. Illinois National Insurance Company, Case No. 48-2004-SC-4734-O (Orange Cty. Ct., November 6, 2005) [13 Fla. L. Weekly Supp.354b]; Florida Emergency Physicians Kang & Associates, M.D., P.A. a/a/o Stephanie Carrico vs. American Vehicle Insurance Company, 12 Fla. L. Weekly Supp. 478b (Fla. Orange Cty. 2005) (Judge Jerry L. Brewer); ROM Diagnostics v. Security National Insurance Company, 9 Fla. L. Weekly Supp 323b (Fla. Orange County 2002) (Judge C. Jeffery Arnold); Integra Diagnostics a/a/o Shawn Umstead v. Reliance National Indemnity Company, 8 Fla. L. Weekly Supp. 394c (Fla. Broward Cty. Ct. 2001); Palm Beach Regional MRI, Inc. (Cynthia Jackman) v. Southern Group Indemnity, Inc., 11 Fla. L. Weekly Supp. 742a (Cty Ct., 15th Jud. Cir. 2004).
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