14 Fla. L. Weekly Supp. 99b
Insurance — Personal injury protection — Explanation of benefits — Failure to provide — Insurer that failed to comply with statutory mandate to furnish itemized specification of unpaid charges to medical provider breached insurance contract — Letter filed in opposition to summary judgment is legally deficient where letter explains reason for suspension of chiropractic benefits after suspension date, but provider’s services were orthopedic services provided prior to suspension date — No merit to insurer’s argument that it was merely required to provide explanation, but that explanation need not be correct or understandable
R.J. TRAPANA, M.D., P.A., a Florida Corporation (assignee of Zuleta, Jesus), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-00777 COSO 60. October 23, 2006. Sharon L. Zeller, Judge. Counsel: Russel Lazega. Andrew W. Edwards.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT I OF COMPLAINT (BREACH OF CONTRACT RE: ITEMIZEDSPECIFICATION OF UNPAID CHARGES/EOB)
THIS CAUSE came before the Court on hearing on Plaintiff’s Motion for Summary Judgment (Count I — Breach of Contract regarding itemized specification of unpaid charges), 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 asfollows:
Background: This is a multi-count P.I.P. case. Count I of Plaintiff’s Complaint pleads that Defendant breached its insurance contract by failing to provide Plaintiff with a legally compliant Explanation of Benefits (commonly known as an EOB) and that Plaintiff is entitled to attorney’s fees and costs related to Count I for the necessity of bringing an action to enforce this statutory obligation. Defendant has presented no proper record evidence showing that it furnished the required itemized specification.
Conclusions of Law. 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); Mia A. Higginbotham, D.C., P.A. v. United Automobile Ins. Co., 11 Fla. L. Weekly Supp. 748 (Broward Cty. Ct. 2004), and that accordingly, the provision of Florida Statute s. 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 Goldson v. United Auto. Ins. Co. (Decision of Judge Robert Lee, Broward County case # 03-7459 COSO 62); 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 (Decision of Judge Sharon Zeller, Broward County Case 03-3115 COSO 60). As a result, when the Defendant failed to comply with the mandatory provisions of Fla. Stat. §627.736(4)(b), it breached its insurance contract with the insured. Plaintiff has met the requisite burden to show that the required information was not furnished to the Plaintiff and Defendant has presented no proper record evidence to show a genuine disputed issue of material fact as to this question. Defendant has offered only the affidavit of a litigation adjuster attesting that the attachment to the affidavit was sent to Plaintiff. Without addressing whether the affidavit is legally sufficient (i.e. timely filed, predicated upon a proper foundation of personal knowledge, etc.) the Court finds that the attached letter which was allegedly sent to Plaintiff is legally deficient. The letter filed in opposition to Summary Judgment addresses and attaches a chiropractic peer review explaining the reason for suspension of CHIROPRACTIC BENEFITS AFTER THE SUSPENSION DATE. Plaintiff’s services were orthopedic services rendered by a medical doctor, before the suspension date. Defendant responds that it is only required to give an explanation and that the explanation need not be correct or understandable. The Court rejects this argument and finds that such an approach would turn the legislative intent on its head and do nothing to explain to consumers how their claims are being processed so that needless litigation is avoided. Accordingly, it is hereby
ORDERED AND ADJUDGED the Plaintiff’s Motion for Summary Judgment is GRANTED. Summary judgment is entered in favor of Plaintiff as to liability and at a minimum nominal damages on Count I of the Complaint. Plaintiff is the prevailing party as to Count I and pursuant to Florida Statute 627.428, Plaintiff has obtained a “judgment or decree” entitling Plaintiff to recover from Defendant attorney’s fees and costs as to Count I in an amount to be determined at a later hearing. The court reserves jurisdiction to determine the amount of fees and costs.
