14 Fla. L. Weekly Supp. 103b
Insurance — Personal injury protection — Claim form — Professional license number — Insurer’s failure to notify medical provider for two years after receipt of claims that claims were defective due to absence of professional license number constituted waiver of defense — Further, insurer that was able to proceed as normal with claims investigation has not demonstrated prejudice caused by alleged deficiency in claim formsREVERSED at 16 Fla. L. Weekly Supp. 37a
HOWARD J. GELB M.D., P.A., (Noreen Schacht, Patient), Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, a Florida corporation, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 05-019706 (52). October 27, 2006. Jay S. Spechler, Judge. Counsel: Andrew J. Weinstein, Weinstein & Associates, P.A., Coral Springs, for Plaintiff. Magalis Perez, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT ON BOX 31 DEFENSE
THIS CAUSE came before the Court on October 5, 2006 for hearing of Plaintiff’s Motion For Partial Summary Judgment regarding Defendant’s Box 31 Defense; the Court having reviewed the Motion and entire Court file; heard arguments; reviewed relevant legal authorities; and been sufficiently advised on the premises, the Court finds as follows:
Background:
1. The above styled cause of action arises out of an action for unpaid personal injury protection benefits.
2. The Claimant, Noreen Schacht, came under the care of the Plaintiff, Howard J. Gelb, M.D., P.A. who treated the Claimant from December 22, 2003 through June 10, 2004.
3. Plaintiff submitted to Defendant a series of 15 claims for payment from January 2, 2004 through June 22, 2004. Defendant failed to submit payment for any of the claims submitted.
4. On October 23, 2005 the Plaintiff filed its Complaint seeking payment of the aforementioned claims.
5. On January 9, 2006 the Defendant filed its Answer and Affirmative Defenses to the Plaintiff’s Complaint.
6. In paragraph #11 of Defendant’s Answer and Affirmative Defenses, Defendant contends that Plaintiff failed to properly fill out the HCFA claim forms, in that Box 31 did not contain a medical license number. Defendant further contends that pursuant to Florida Statute § 627.736(5)(d), Defendant has not yet been furnished with statutory notice and bills are not overdue.
7. Defendant never sent the Plaintiff an explanation of benefits and did not notify the Plaintiff that the claims submitted would not be paid due to an alleged deficiency with Plaintiff’s HCFA forms.
8. Pursuant to Florida Statute § 627.736(5)(d) claim forms must be substantially complete as to all the material elements of the claim form. This Court finds the forms submitted by Plaintiff did in fact meet this statutory requirement.
Conclusions of Law:
Plaintiff is in compliance with all billing requirements set forth under Florida Statute § 627.736(5)(4)(d). The claims submitted by the Plaintiff contain all of the requisite information called for under Florida Statute § 627.736(5)(4)(d), which is the controlling authority on this issue. Plaintiff’s HFCA forms contained the required signature, credentials, and a universal provider identification number.
“A review of Florida cases involving construction of expressions similar to “substantial completion” indicates that a court should overlook mere technical deficiencies and instead look at whether the party is provided with material information necessary to permit clear review.” Garcia v. United Automobile Ins. Co., 12 Fla. L. Weekly Supp. 888b (2005). Plaintiff is in compliance with the statutory requirements.
Defendant failed to apprise the Plaintiff that the claims submitted would not be paid based on Box 31 not being “properly” filled out. The deposition of the Defendant’s Litigation Adjuster, Richard Miranda was conducted on March 23, 2006, which was more than four months after the Defendant received Plaintiff’s claims. During the deposition, Mr. Miranda was asked a series of questions regarding the defenses to Plaintiff’s claims, at no time during the deposition did the adjuster raise the HCFA forms as a defense, or even make mention that they were an issue.
Defendant’s own actions prevented the Plaintiff from rectifying the alleged claim form defect. Insurers have a duty to provide an explanation of benefits that disclose the reasons for nonpayment, especially when the issues can be easily resolved. World Health Chiropractic & Rehabilitation v. Nationwide Property and Casualty, 12 Fla. L. Weekly Supp. 594b (2005). Plaintiff could have resubmitted the claims in compliance with the Defendant’s request without difficulty.
Defendant obtained both an examination under oath as well as an independent medical examination of the insured during their investigation, without ever requesting the information in Box 31, that Defendant claims is critical to its investigation. (See Miranda depo at pg 28, lines 8-18). “The license number of the provider does not provide any information that the carrier needs to evaluate, investigate or pay a claim.” World Health Chiropractic & Rehabilitation, Inc. v. Nationwide Property and Casualty Insurance Co., at 12 Fla. L. Weekly Supp. 594b (2005).
Defendant’s failure to notify the Plaintiff that claims submitted were defective constituted a waiver of the defense. Waiver is defined as “the intentional or voluntary relinquishment of a known right or conduct which warrants an inference of the relinquishment of a known right”. Benedict v. Pensacola Motor Sales, Inc., 846 So. 2d 1238 (Fla 1st DCA 2003). Defendant had ample opportunity to apprise the Plaintiff that they considered the claims defective and would not be providing benefits. However, the Defendant continued to investigate the claim, and on July 14, 2004, seven months after receiving the Plaintiff’s claims, the Defendant sent Plaintiff a status letter. Not only did Defendant’s status letter not meet the requirements of an explanation of benefits, but the only indication for nonpayment was exhaustion of benefits.
Defendant’s first indication that Box 31 was a defense to the claim was in their Answer and Affirmative Defenses filed on January 9, 2006, almost two years after they received notice of the Plaintiff’s claims.
Conclusion:
Defendant’s affirmative defense that Plaintiff did not properly fill out Box 31 of the HCFA form is without merit. Plaintiff submitted said claims in full compliance with the statutory requirements of Florida Statute § 627.736(5)(4)(d). Defendant may not choose to deny payment of medical claims based on groundless affirmative defenses.
Defendant had the opportunity to allow the Plaintiff to remedy any alleged claim form defect and resubmit said claims in compliance with the Defendant’s wishes.
Defendant has not met the burden of establishing any prejudice to the investigation cause by the alleged deficiency in Plaintiff’s claim forms. As discussed above, the Defendant was able to proceed as normal with the investigation of their claim. Prejudice is one of the key factors considered by the court, and in the instant case there is none present. World Health Chiropractic & Rehabilitation, Inc., at 12 Fla. L. Weekly Supp. 594b.
Accordingly, it is ORDERED and ADJUDGED, the Plaintiff’s Motion for Partial Summary Judgment on Defendant’s Box 31 Defense is hereby granted.
