14 Fla. L. Weekly Supp. 496a
Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Breach of contract action is proper against insurer that failed to furnish medical provider with EOB for unpaid charges
NDNC NEUROLOGICAL TREATMENT CENTERS, INC. (a/a/o Mercedes Medina), vs. UNITED AUTOMOBILE INSURANCE COMPANY. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-010052 COCE (52). March 2, 2007. Jay S. Spechler, Judge. Counsel: Emilio R. Stillo, South Florida Trial Lawyers LLC, Pompano Beach. Jason Lopez, Office of the General Counsel.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT II OF PLAINTIFF’S COMPLAINT (BREACH OF CONTRACT SEEKING ITEMIZED SPECIFICATION OF UNPAID CHARGES/EOB)
THIS CAUSE came before the Court on March 2, 2007 for hearing on Plaintiff’s Motion for Summary Judgment (Count II — Breach of Contract seeking itemized specification of unpaid charges/EOB), 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. On or about July 11, 2006, having not received from Defendant the required statement of the reasons for non-payment of its charges, the Plaintiff filed its Complaint against the Defendant for Breach of Contract seeking an itemized specification of unpaid charges/Explanation of Benefits itemizing the charges received by Defendant from Plaintiff and detailing the reasons for nonpayment. The gist of Count II is that the Defendant failed to provide the explanation of benefits required by Florida Statute § 627.736(4)(b).
Defendant has presented no record evidence showing that it furnished the itemized specification.
In fact, Defendant’s own adjuster testified in deposition as follows:
Q: What documents does United contend to have furnished, which are an explanation of benefits, to either Mr. Avrunin or to NDNC?
A: We don’t have an explanation of benefits sent.
Conclusions of Law. As pertains to the issue in this Motion, Florida Statute § 627.736(4)(b) provides: “When an insurer pays only a portion of a claim or rejects a claim, the insurer shall provide at the time of the partial payment or rejection an itemized specification of each item that the insurer had reduced, omitted, or declined to pay and any information that the insurer desires the claimant to consider related to the medical necessity of the denied treatment or to explain the reasonableness of the reduced charge, [. . .]; and the insurer shall include the name and address of the person to whom the claimant should respond and a claim number to be referenced in future correspondance” (emphasis added). This is generally informally referred to as an “explanation of benefits.”
The Plaintiff is correct 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 § 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 Automobile 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 Automobile Insurance 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 policy is sound (avoiding needless litigation and fostering open communication regarding claims submissions). It is also expressly mandated by the statute.
ORDERED AND ADJUDGED THAT: the Plaintiff’s Motion for Summary Judgment is GRANTED in favor of Plaintiff as to Count II of the Complaint. As to Count II 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.
