13 Fla. L. Weekly Supp. 1111a
Insurance — Personal injury protection — Declaratory judgment — Insurer’s obligation to provide policy, declarations page and PIP log on pre-suit request from medical provider/assignee — Declaratory judgment is proper vehicle for determining insurer’s obligation to provide pre-suit information — Insurer was required to provide pre-suit information, including policy, declarations page and information that would otherwise be compiled in PIP log on pre-suit request from provider — Attorney’s fees and costs awarded to provider
LEESBURG CHIRO CENTER, INC., a/a/o KEVIN WALTER, Plaintiff, vs. PROGRESSIVE EXPRESS INS. CO., Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 04-SC-2070. August 28, 2006. John R. Sloop, Judge. Counsel: Michael Tierney, Michael Tierney, P.A., Winter Park. George Milev, Orlando.
ORDER
THIS CAUSE having come before the Court and the Court having reviewed the Motion(s) being otherwise duly advised in the premises, hereby notes the following:
UNDISPUTED FACTS
The insured received care and treatment from the Plaintiff. During the scope of said treatment, the insured executed an assignment of benefits to the Plaintiff. The Plaintiff subsequently submitted a bill for care and treatment of the insured to the Defendant, along with a copy of the assignment of benefits. Defendant unilaterally reduced the bill, and benefits were subsequently exhausted. In response to their bill being unpaid, on May 18, 2004, the Plaintiff sent a written request, with the assignment of benefits, to the defendant requesting a copy of the insured’s declaration sheet and pip log as part of their pre-suit investigation to confirm if benefits were properly exhausted. The Plaintiff waited 70 days before filing their declaratory judgment count, regarding the Defendant’s failure to disclose the dec sheet and pip log.
The Plaintiff filed suit because they were left in doubt asto whether benefits remained, whether the policy paid at 80% or 100%, and whether there was any med-pay available under the policy, and if benefits were exhausted. However, after the suit was filed, the defendant provided the dec sheet to the Plaintiff, AFTER suit was filed.
Now the Plaintiff seeks Final Summary Judgment and a Declaratory Judgment on the following:
1) The Defendant insurer was required to provide pre-suit, a copy of the insurance policy, declarations page and PIP log;
2) Failure to provide the requested information is a proper question for Declaratory Judgment.
LAW AND ANALYSIS
The Plaintiff has a right to obtain the requested documentation in order to confirm whether benefits were exhausted in this claim. Furthermore, the Plaintiff needed to verify insurance coverage and available benefits, and not have to rely on defendant’s assertion that benefits were exhausted. This Court agrees that a health care provider, who has a valid assignment of benefits, has a right to determine, pre-suit, what claims have been made and when; how much PIP/med pay benefits remain; and whether benefits have truly been exhausted. The Plaintiff has a right to a copy of the insurance policy and the declarations page. This is not a statutory requirement under F.S. 627.736, or elsewhere and these requests are not subject to time constraints or demand letters. Trial courts and circuit appellate decisions have found that providing claims and coverage information is essential to a health care provider’s ability to verify their status as a PIP claimant. Furthermore, the Court finds that by disclosing this information from an insurer to an insured, or its assignee, is in conformity with the intent of the PIP statute. See Allstate v. Ivey Ins. Co., 774 So.2d 679, 683.84 (Fla. 2000) (quoting Government Employees Ins. Co. v. Gonzalez, 512 So.2d 269, 271 (Fla. 3d DCA 1987). To rule otherwise places providers in a position of solely believing the insurer without a method of confirming their assertions, and putting the Plaintiff in a position of facing sanctions under 57.105.
This ruling is consistent with the holding in New Hampshire Indemnity Ins. Co. v. Rural Metro Ambulance, a/a/o William Zaniboni, 04-72AP (Seminole Cty. Ct., November 18, 2005).
For the reasons cited above, this Court GRANTS Plaintiff’s Motion for Summary Judgment and FINDS:
1) The Declaratory Judgment is a proper vehicle for the relief requested in this case.
2) The Defendant was required to provide pre-suit information including a copy of the insurance policy and declarations page and the information set forth in Zaniboni.
3) The failure to provide pre-suit information necessary to determine the merits of the denial of claim entitles Plaintiff to an award of attorney fees and costs. The Court reserves jurisdiction to determination of amount of fees and costs.
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