14 Fla. L. Weekly Supp. 94a
Insurance — Personal injury protection — Explanation of benefits — Where insurer sent letter to insured’s attorney advising that no benefits would be paid due to missed independent medical examination, and thereafter insured received treatment from medical provider, insurer was required to provide EOB to provider regarding ensuing claim — Because statute requires explanation for each item claimed and provider’s claim was not part of claim made by insured, insurer was obligated to explain denial of claim, even if it merely repeated previous denial
R.J. TRAPANA, M.D., P.A. (a/a/o Karen Hamilton), Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-9475 COCE 53. October 9, 2006. Robert W. Lee, Judge. Counsel: Russel Lazega, North Miami, for Plaintiff. George D. Shirejian, Coral Gables, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT I OF COMPLAINT
THIS CAUSE came before the Court on October 6, 2006 for hearing of the Plaintiff’s Motion for Summary Judgment as to Count I of the Complaint, and the Court’s having reviewed the Motion, Court file, and relevant legal authorities; having heard argument; and having been sufficiently advised in the premises, the Court hereby finds as follows:
Florida Statute §627.736(4)(a) provides in pertinent part: “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” (emphasis added). Under the controlling appellate authority in this Circuit, this provision can be enforced through a breach of contract action. The Defendant does not dispute this ruling. Rather, the Defendant argues that it does not apply to the situation in this case.
The Defendant alleges that on June 5, 2003, it sent a letter to the patient’s provider, advising that no PIP benefits would be paid because the patient missed a scheduled independent medical examination (IME). Three weeks later, the patient saw Dr. Trapana for an orthopaedic consultation. The Plaintiff alleges that it timely submitted the bill to United Automobile, which did not respond. The Defendant acknowledges that it did not send anything to the Plaintiff in response to the bill. The Defendant argues it was not obligated to do so because of its June 5th declination letter to the patient’s attorney. The Defendant further argues that the Plaintiff, as assignee, stands in shoes of the patient, and the June 5th notice to the patient is imputed to the Plaintiff. The Court disagrees.
The statute requires, by use of the word “shall,” that the insurer provide an explanation of benefits when it receives a claim if the claim is rejected in whole or denied in part. The Plaintiff’s claim in this case was not part of the claim made by the patient. Therefore, when the Plaintiff submitted a new claim to the insurer, the insurer was obligated to explain its denial, even if it merely parroted the previous denial sent three weeks earlier to the patient. Otherwise the Legislature would not have required an explanation for “each item” denied. Accordingly, it is hereby
ORDERED AND ADJUDGED that Plaintiff’s Motion for Summary Judgment as to Count I of the Complaint is GRANTED.
