14 Fla. L. Weekly Supp. 886a
Insurance — Personal injury protection — Demand letter — Sufficiency — Demand letter to which itemized statement and HCFA form were attached was sufficient — Even if letter were not sufficient, insurer’s failure to respond to letter or issue explanation of benefits would have resulted in waiver of demand letter defense
STAND UP MRI OF BOCA RATON, P.A., (Jorge Herrera, Patient), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 07-001266 (51). July 3, 2007. Martin R. Dishowitz, Judge. Counsel: Andrew J. Weinstein, Weinstein & Associates, P.A., Coral Springs, for Plaintiff. Kelly Eckley, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT ON DEMAND LETTER DEFECT DEFENSE AND DENYING DEFENDANT’SMOTION FOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on May 17, 2007 for hearing of Plaintiff’s Motion for Partial Summary Judgment on the Demand Letter Defect Defense and the Defendant’s Motion for Final Summary Judgment, the Court having reviewed the Motion and entire Court file; heard argument; reviewed relevant legal authorities; and been sufficiently advised on the premises, the Court finds as follows:
1. On November 9, 2004, Jorge Herrera sustained injuries in an automobile accident for which he sought treatment from the Plaintiff. Plaintiff timely submitted its bill to the Defendant, UNITED AUTOMOBILE INSURANCE COMPANY (hereinafter “UNITED”). UNITED did not pay the bill.
2. On June 13, 2005, Plaintiff STAND UP MRI of BOCA RATON, P.A. submitted its “Demand Letter Under FL Statute 627.726(11)” to the Defendant, UNITED AUTOMOBILE INSURANCE COMPANY (hereinafter “UNITED”). UNITED time-stamped the Demand Letter as received on June 21, 2005. UNITED neither responded to the Demand Letter nor provided any Explanation of Benefits to the Plaintiff.
3. On September 14, 2006, Plaintiff filed its Complaint seeking payment for the unpaid bill.
4. Florida Statute 627.736(11) states that the demand letter shall state with specificity, “to the extent applicable, the name of the medical provider who rendered to an insured the treatment, services, accommodations, or supplies that form the basis of such claim; and an itemized statement specifying each exact amount, the date of treatment, service, or accommodation, and the type of benefit claimed to be due. A completed form satisfying the requirements of paragraph (5)(d) or the lost wage statement previously submitted may be used as the itemized statement.”
5. Plaintiff’s Demand Letter of June 13, 2005 attached both the itemized statement and the HCFA form previously submitted to UNITED, each form specifying the exact amount, date of treatment, services/accommodations and the type of benefit claimed to be due.
6. Plaintiff bases its contention that the Demand Letter was legally sufficient on Open MRI of Miami-Dade Ltd. a/a/o Joseph Vincent v. Progressive Express Insurance Co., No. 0492014 (Fla. 11th Cir. Ct. Dec. 25, 2005). “The statute contemplates two alternative means by which the party sending the pre-suit demand may advise the insurance company of the dates of service and the types of services at issue. First, the statute provides that the party sending the pre-suit demand may include with the demand letter an ‘itemized statement’ created for the purposes of inclusion with the pre-suit demand letter. . . Alternatively, the statute also expressly provides that instead of creating an itemized statement for use with the demand letter, the HCFA form previously submitted may be used as an itemized statement.” Id.
7. Defendant bases its contention that the Demand Letter is defective on Rose Radiology Centers, Inc., a/a/o Angelo Cianciatto v. State Farm Mutual Automobile Insurance Company, which states that, “there is no requirement set forth in § 627.736 Florida Statutes that requires an insurer to make a determination as to what amount and what is to be paid for the services/treatment in order to satisfy Plaintiff’s Demand.”
8. Even if the Defendant were to contend that the amount billed for the MRI was excessive, “any amount billed in excess of the statutorily preset fee does not relieve the insurer from paying the reimbursable amount,” United Automobile Insurance Co. v. A-1 Mobile MRI, Inc. a/a/o Michael Emekekwue, 12 Fla. L. Weekly Supp. 540b (Fla. 17th Cir. Ct. Mar. 2, 2005).
9. Furthermore, UNITED sent no Explanation of Benefits in response to the original claim submission. It is incumbent upon the insurer to provide the Plaintiff with an itemized specification of reduced or rejected claims detailing the reason for nonpayment, per Florida Statute 627.736(4)(b). “Pursuant to Florida Statutes 627.736(4)(b), an itemized specification requires a charge by charge specification, stating why the bill was denied or reduced, and what is specifically needed to process the claim,” Mandell Chiropractic & Rehabilitation Centre v. United Automobile Insurance Co., 12 Fla. L. Weekly Supp. 396a (17th Cir. Ct. Sep. 29, 2004). “Not only is such an itemized statement required by Florida Statutes 627.736(4)(b), but it makes good sense on public policy grounds because the prompt exchange of information before suit is filed reduces the amount of litigation filed and allows claimants to resolve or correct problems with claims before suit is filed,” id. “Providers armed with the information provided by an itemized specification can make informed decisions as to where they stand in relation to their submitted claims. . . to rule otherwise would place the provider in an untenable ‘Catch-22′ position of having to sue when it is in the dark, and then being faced with exposure for the imposition of Section 57.105(1), F.S., attorney’s fees when it learns that an insurance company properly reduced or denied a medical bill,” id.
10. This Court finds that the Demand Letter submitted by the Plaintiff was sufficient as a matter of law, and that, even if the Demand Letter were insufficient, UNITED’s failure to respond to the Demand Letter or to issue an Explanation of Benefits as to why the claim would not be paid would have resulted in a waiver of this defense.
Accordingly, it is ORDERED and ADJUDGED, the Plaintiff’s Motion for Partial Summary Judgment as to Defendant’s Demand Letter Defect Defense is hereby GRANTED, and Defendant’s Motion for Final Summary Judgment is hereby DENIED.
