13 Fla. L. Weekly Supp. 1098b
Insurance — Personal injury protection — Explanation of benefits — Failure to provide — 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 — No merit to argument that insurer was only obligated to furnish EOB to insured or that insurer was relieved of duty to provider by furnishing EOB to insured where statute clearly requires that EOB be furnished to entity making claim — Attorney’s fees and costs awarded to provider
SOUTH FLORIDA PAIN AND REHABILITATION, P.A., a Florida Corporation (assignee of Brown, Mary), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-0665 COSO 60. August 25, 2006. Sharon Zeller, Judge. Counsel: Russel Lazega, Law Office of Russel Lazega, North Miami, for Plaintiff. Andrea Harris, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT IOF COMPLAINT (BREACH OF CONTRACT REGARDING ITEMIZED SPECIFICATIONOF UNPAID CHARGES/EOB)
THIS CAUSE came before the Court on August 25, 2006 for hearing on Plaintiff’s Motion for Summary Judgment as to Count I (Breach of Contract — regarding 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: This is a P.I.P. Suit. Count I of Plaintiff’s complaint alleges breach of contract for failure to furnish an itemized specification of unpaid charges (a/k/a an explanation of benefits or “EOB”). Specifically, Plaintiff alleges that Defendant was required by F.S. s. 627.736(4)(b) to furnish Plaintiff with an EOB, that the provisions of Florida Law governing insurance contracts are deemed incorporated into all insurance contracts, and that Defendant therefore breached the insurance contract by failing to comply with the statute. In response, Defendant identifies two (2) letters sent to the patient’s attorney (not the Plaintiff or Plaintiff’s attorney) citing an independent medical examination suspension and coverage issues. Defendant suggests that notification to the patient (or patient’s attorney) is notice to the provider because the medical provider accepted an assignment of benefits and therefore stands in the shoes of the insured/patient.
Conclusions of Law. The Plaintiff iscorrect 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), 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 e.g. United Auto. Ins. Co. v. R.J. Trapana, M.D., P.A., 12 Fla. L. Weekly Supp. 452 (Decision of Judge Richard Eade, Circuit Court, Broward County in its appellate capacity 2005); United Auto. Ins. Co. v. Stat Technologies, Inc., 13 Fla. L. Weekly Supp. 37c (Decision of Judge John Luzzo, Circuit Court, Broward County, in its appellate capacity 2005). As a result, Defendant was obligated to furnish Plaintiff with an itemized specification of the unpaid charges and the reasons for non-payment. The court is not persuaded by the argument that the insurer has only an obligation to furnish the insured with the information or that the insurer is relieved of any obligation to the provider by furnishing information to the insured. The statute is clear — when the insurer “pays only a portion of a claim or rejects a claim, the insurer shall provide at the time of partial payment or rejection an itemized specification of each item that the insurer had reduced, omitted or declined to pay . . .” The statute further directs that this information be furnished to the claimant — in other words, the personor entity making the claim. In the instant case, the assignee medical provider submitted a claim and is entitled to know why it is not being paid. The policy is sound (avoiding needless litigation and fostering open communication regarding claims submissions). It is also expressly mandated by the statute.
Accordingly, it is hereby
ORDERED AND ADJUDGED the Plaintiff’s Motion for Summary Judgment is GRANTED. Summary judgment isentered in favor of Plaintiff as Count I of the Complaint. As to Count I, Plaintiff is the prevailing party. Pursuant to Florida Statute 627.428, Plaintiff is entitled to recover from Defendant attorney’s fees and costs as to this Count in an amount to be determined at a later hearing, for which, the court reserves jurisdiction.
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