13 Fla. L. Weekly Supp. 160a
Insurance — Personal injury protection — Explanation of benefits — Where, upon receipt of bill for cervical pillow, insurer sent EOB making timely request for invoice for pillow, and provider did not send invoice but instead filed suit, EOB tolled time for payment, and claim for pillow was not overdue at time suit was filed — No merit to argument that only way insurer could request invoice under section 627.736(6)(b) is if it requested all information listed in section, including sworn statement that services rendered were reasonable and necessary
THE WITTMER CLINIC OF CHIROPRACTIC, P.A. as assignee of CHRISTOPHER HAMIL, Plaintiff, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. SCO-03-5690. October 3, 2005. Nancy L. Clark, Judge. Counsel: George Milev, Adams & Diaco, P.A., Tampa. Mark Cornelius.
ORDER ON DEFENDANT’S MOTION FOR PARTIALSUMMARY JUDGMENT AND PLAINTIFF’S MOTIONFOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE having come before the Court on Defendant’s Motion for Partial Summary Judgment and Plaintiff’s Motion for Partial Summary Judgment on September 14, 2005, the Court having heard arguments by counsels for Plaintiff and Defendant and otherwise being fully advised in the premises, hereby
FINDS, ORDERS AND ADJUDGES as follows:
1. Plaintiff filed the above styled PIP lawsuit against Defendant alleging breach of automobile insurance contract.
2. Plaintiff claimed in its Complaint that Defendant has failed to reimburse Plaintiff amongst other things for a cervical pillow, cpt code E0943, provided to Christopher Hamil for date of service March 20, 2003.
3. Plaintiff is a medical provider which filed the above styled lawsuit as an assignee of Christopher Hamil who was involved in an auto accident on or about March 15, 2003.
4. Defendant received the HCFA bill from Plaintiff containing the charge for said cervical pillow on March 30, 2003.
5. Upon receipt of that bill, Defendant generated an Explanation of Benefits (EOB) in which Defendant requested that Plaintiff “submit an invoice from the supplier to determine proper payment for medical appliances/equipment” (the cervical pillow).
6. Said Explanation of Benefits was sent to Plaintiff on April 17, 2003.
6. Plaintiff did not provide Defendant with an invoice for the cervical pillow but instead filed the above styled lawsuit on May 22, 2003.
7. Defendant argues that the request for invoice was made pursuant to §627.736(6)(b), Fla. Stat. (2003), although the Statute is not cited on the Explanation of Benefits provided to Plaintiff.
8. §627.736(6)(b), Fla. Stat.(2003) reads in its pertinent part:
Every physician. . . providing, before or after bodily injury upon which a claim for personal injury protection benefits is made, any products. . . shall, if requested to do so by the insurer. . . furnish forthwith a written report of. . . costs of such treatment. . . and produce forthwith. . . his or her or its records regarding such. . . costs of treatment. . . If an insurer makes a written request for documentation or information. . . within 30 days after having received notice of the amount of a covered loss. . . the amount or partial amount shall become overdue if the insurer does not pay . . . within 10 days after the insurer’s receipt of the requested documentation or information. . .” (emphasis added).
9. Plaintiff argues that the only way Defendant’s request for an invoice can comply with §627.736(6)(b), Fla. Stat. (2003) is if Defendant had requested all the information/documents listed in subsection (6)(b) including a sworn statement that the treatment or services rendered were reasonable and necessary.
10. It is undisputed that Plaintiff received the request for invoice for the cervical pillow and chose to ignore it. See p. 15, lines 8-19 and p. 16, lines 8-10 of the deposition of Denise Cerabino on February 24, 2004, and p. 9, lines 4-6 of the deposition of Scott Wittmer on March 17, 2004.
11. Defendant made timely request for information or documentation pursuant to §627.736(6)(b), Fla. Stat. (2003), thus tolling the time for payment of the cervical pillow charge.
12. To require Defendant to request all of the information listed in §627.736(6)(b), Fla. Stat. (2003) in order for Defendant’s request for invoice to comply with subsection (6)(b) is not in accordance with the obvious meaning of the Statute.
13. This Court finds that under the plain language of the Statute, an insurer can request documentation or information from a medical provider pursuant to §627.736(6)(b), Fla. Stat. (2003) without requesting also a sworn statement that the treatment or services rendered were reasonable and necessary.
14. The claim for the cervical pillow charge was not overdue at the time the current lawsuit was filed as Plaintiff did not respond to Defendant’s request prior to filing of lawsuit.
WHEREFORE, Defendant’s Motion for Partial Summary Judgment is hereby GRANTED and Plaintiff’s Motion for Partial Summary Judgment is hereby DENIED.
