14 Fla. L. Weekly Supp. 796a
Insurance — Personal injury protection — Claim form — Professional license number — Insurer was not placed on notice of covered loss where medical provider failed to include professional license number on CMS 1500 forms
MAGIC CHIROPRACTIC CLINIC, INC., as assignee of VERKESHA R. MATTHEWS, Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 06-SC-6332. June 18, 2007. Antoinette Plogstedt, Judge. Counsel: David Dougherty, Coury Law Firm, P.A., Lake Mary. Eric Biernacki, Adams & Diaco, P.A., Orlando.
SUMMARY FINAL JUDGMENT
This CAUSE having come before this Court on Defendant’s Motion for Summary Final Judgment and Motion for Protective Order, and the Court having heard the argument of counsel, and being otherwise fully advised in the premises, finds as follows:
1. Plaintiff filed a PIP suit, as assignee of Verkesha Matthews, against Defendant for reduced and unpaid medical bills for treatment allegedly rendered to Verkesha Matthews, for dates of service September 30, 2005 through November 25, 2005, as a result of injuries allegedly sustained in an automobile accident which occurred on September 29, 2005. More specifically, Plaintiff filed suit because Defendant reduced some of Plaintiff’s bills and denied the others based on the insured’s failure to attend examinations under oath.
2. Defendant subsequently discovered that the Centers for Medicare and Medicaid Services (CMS) 1500 forms Plaintiff submitted to Defendant, regarding the treatment allegedly rendered to Verkesha Matthews for dates of service September 30, 2005 through November 25, 2005, did not contain the credentials or professional license number of the provider in Box 31 or anywhere else on said CMS 1500 forms.
3. Defendant argued that it was not placed on notice of a covered loss due to Plaintiff’s failure to provide Defendant with properly completed CMS 1500 forms, as required by Florida Statutes §627.736(5)(d) (2005).
4. Florida Statutes §627.736(5)(d) in its pertinent part states:
“All . . . bills for medical services rendered by any physician, hospital, clinic . . . shall be submitted to the insurer on a properly completed . . . (CMS) 1500 form . . . . All providers other than hospitals shall include on the applicable claim form the professional license number of the provider in the line or space provided for “Signature of Physician or Supplier Including Degrees or Credentials” . . . . For purposes of paragraph (4)(b), an insurer shall not be considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph, and unless the statements or bills are properly completed in their entirety as to all material provisions. . . .” (emphasis added)
5. When the language of the statute is clear and unambiguous, and conveys a clear and definite meaning, the statute must be given its plain and obvious meaning. State of Florida v. Warren, 796 So. 2d 489 (Fla. 2001).
6. It is undisputed that Plaintiff failed to include the professional license number on the CMS 1500 forms it submitted to Defendant.
7. Thus, Plaintiff failed to comply with Florida Statutes §627.736(5)(d) and, in turn, failed to place Defendant on notice of a covered loss for purposes of Florida Statutes §627.736(4)(b). In addition, Florida Statutes §627.736(4)(b) expressly provides that an insurer may raise this defense any time.
8. Florida Statutes §627.736(4)(b) in its pertinent part states:
“Personal injury protection benefits paid pursuant to this section shall be overdue if not paid within 30 days after the insurer is furnished with written notice of the fact of a covered loss . . . . This paragraph does not preclude or limit the ability of the insurer to assert that the claim was . . . in violation of, subsection (5). Such assertion by the insurer may be made at any time, including after payment of the claim or after the 30-day time period for payment set forth in this paragraph.” (emphasis added)
9. This Court finds that Defendant has not waived its defense raised pursuant to subsection (5) of §627.736 because of the express terms contained in the above-referenced subsection 4(b).
10. As such, Plaintiff’s failure to include the professional license number on its CMS 1500 forms precludes Plaintiff from bringing its claim against Defendant.
Accordingly, it is hereby
ORDERED and ADJUDGED that a Summary Final Judgment is hereby entered for the defendant; and it is
ORDERED and ADJUDGED that Plaintiff shall take nothing by this action and Defendant shall go hence without day.
