13 Fla. L. Weekly Supp. 1096b

Insurance — Personal injury protection — Explanation of benefits — Failure to provide — Insurer must furnish medical provider/assignee with EOB specifying each reduced or denied charge and reasons for non-payment, and provider who brings action to enforce statutory right is entitled to attorney’s fees and costs if it prevails — 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

THIRD AVENUE CHIROPRACTIC CENTER, INC., a Florida Corporation (assignee of Nicolas, Lula 2), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-9534 COCE 55. August 24, 2006. Eric Beller, Judge. Counsel: Russel Lazega, Law Office of Russel Lazega, North Miami, for Plaintiff. Jon Sorenson, for Defendant.

ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT I OF COMPLAINT (BREACH OF CONTRACT RE: EOB)

This action was heard on Plaintiff’s Motion for Summary Judgment as to Count I of the Complaint (Breach of Contract regarding EOB), and the Court having considered the arguments, Motions, pleadings and being otherwise advised finds as follows:

FINDING OF FACTS:

This is a 3 count P.I.P. suit. Count I alleges that Defendant was required by Florida Statute 627.736(4)(b) to furnish Plaintiff with an itemized specification of each charge that was submitted by Plaintiff that was reduced or otherwise not paid in full and the reason for nonpayment of each reduced or denied charge. Plaintiff further alleges in its Breach of Contract claim that the provision of Florida law governing insurance contracts are deemed by the Supreme Court of Florida to be part of every contract of insurance issued in this state.(See Grant v. State Farm Fire and Casualty Company, 638 So.2d 936 (Fla. 1994)). The crux of this Count is that Defendant was required by the P.I.P. Statute to furnish Plaintiff with an explanation of benefits (also referred to as an itemized specification of unpaid charges or EOB), that Defendant failed to furnish this information to Plaintiff until it was sued for the information, and that by failing to abide by its statutory obligation, Defendant breached the insurance contract entitling Plaintiff to bring a breach of contract action and recover attorney’s fees and costs pursuant to F.S. s. 627.428. Defendant responds that it furnished an explanation to the insured and other providers and therefore complied with its obligation because the Plaintiff (an assignee medical provider) stands in the shoes of the insured.

LEGAL CONCLUSION:

This Court follows the long line of precedent holding that an insurer must furnish an assignee medical provider with an itemized specification of each reduced or denied charge and the reasons for non-payment and that a claimant or assignee medical provider who brings an action to enforce the statutory right is entitled to attorney’s fees and costs if it prevails. United Auto. Ins. Co. v. R.J. Trapana, M.D., P.A., 12 Fla. L. Weekly Supp. 452a (2005) (Decision of Judge Richard Eade) Circuit Court, Broward County (Appellate) Review Denied by 4th District Court of Appeal; United Auto. Ins. Co. v. Stat Technologies, Inc., 13 Fla. L. Weekly Supp. 37 (2005) (Decision of Judge John Luzzo, Circuit Court, Broward County) (Appellate); Miami Chiropractic Associates v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 677 (2004) (Decision of Judge Jay Spechler, Broward County); Mia A. Higginbotham, D.C., P.A. v. United Automobile Ins. Co., 11 Fla. L. Weekly Supp. 748 (2004) (Decision of Judge Robert W.Lee, County Court, Broward County 2004); Primary Care Medical Group, Inc. v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 493a (Decision of Judge Lisa Trachman, Broward County 2005); Fidel S. Goldson, D.C. v. United Auto. Ins. Co. 12 Fla. L. Weekly Supp. 161b (Decision of Judge Robert Lee, Broward County 2004); STAT Technologies, Inc. v. United Auto. Ins. Co., (Decision of Judge Lee Jay Seidman, Broward County Case 02-01929 COSO 62); All Care Health & Wellness v. United Auto. Ins. Co. (Decision of Judge Sharon Zeller, Broward County Case 03-3115 COSO 60); Mandell Chiropractic and Rehabilitation Centre (a/a/o James Roosevelt), v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 396a (2004) (Decision of Judge William Herring, County Court, Broward County); Silver Chiropractic Center v. United Auto. Ins. Co. (Unpublished Decision of Judge Caryn Canner-Schwartz, Dade County (2005) Case # 04-01510 SP 23); and Orthopedic Health Center, Inc. v. United Auto. Ins. Co. (Unpublished Decision of Judge Myriam Lehr, Dade County (2005) Case # 05-06061 CC 23); Countyline Chiropractic Center, Inc. v. United Auto. Ins. Co. (Unpublished Decision of Judge Linda Singer-Stein (2005) Dade County Case #04-2482 CC 23). The Defendant in response to second interrogatories acknowledges that the Plaintiff was not furnished an explanation as to its charges until after suit, which amounts to a confession of judgment. 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 person or 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 ADJUDGED that

1. Plaintiff’s Motion for Summary Judgment as to Count I is Granted.

2. Plaintiff is entitled to recover reasonable attorney’s fees and costs incurred in prosecuting Count I in an amount to be determined at a later hearing, for which the court reserves jurisdiction.

3. The remaining counts shall continue toward trial.

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