14 Fla. L. Weekly Supp. 867a
Insurance — Personal injury protection — Declaratory judgment — Insurer’s obligation to provide policy, declarations page and/or PIP log on presuit request from assignee/medical provider — Tendering PIP log with letter stating extent of alleged coverage under policy did not satisfy insurer’s obligation to provide declarations page requested by provider
THE STAND-UP MRI OF ORLANDO, P.A., as assignee of Yamireth Degracia, Plaintiff, vs. UNITRIN DIRECT PROPERTY & CASUALTY COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 05-SC-4398. July 12, 2007. C. Vernon Mize, Judge. Counsel: Michael Tierney, Michael Tierney, P.A., Winter Park. Brian Forman, Kingsford & Rock, P.A., Maitland.
ORDER
THIS CAUSE having come before the Court, and the Court having reviewed the Motion(s) being otherwise duly advised in the premises, it is hereby
ORDERED AND ADJUDGED:
1. Count II of the Plaintiff’s Complaint is a claim for declaratory relief arising out of a motor vehicle collision that occurred on 04/22/05.
2. The insured executed an assignment of benefits in favor of the Plaintiff.
3. The Plaintiff contacted the defendant to confirm there was an adequate amount of PIP benefits available to pay their bill for MRI services. The defendant said there was at that time. In reliance on the defendant’s information, on 08/03/05, the Plaintiff provided MRI services to the Assignor that were related to the subject automobile accident, medically necessary, and whose amount is controlled by Florida Statutes and submitted their bill timely. However, the defendant later refused to pay the bill stating that benefits were exhausted.
4. Subsequently, on 11/17/05, the Plaintiff sent a Notice of Intent to Initiate Litigation, as well as a request to the Defendant to produce a copy of the declarations page pursuant to Florida Statutes 627.4137, 627.736(6)(d), and 627.7401.
5. The Defendant did not respond to the Plaintiff’s request for a copy of the declarations page.
6. Instead, the defendant provided the PIP log and merely an unsworn letter stating what the alleged coverage was under the policy.
7. It was defendant’s position that the tendering of a PIP log, together with the unsworn letter, that this satisfied the defendant’s obligation to disclose policy information.
8. The Plaintiff waited 34 days, but was left in doubt as to whether it had a claim for breach of contract, as the Defendant failed to provide the information.
9. Thereafter, the Plaintiff filed a Complaint requesting declaratory relief on 12/21/05.
10. To date, the Defendant has not provided the Dec Sheet to the Plaintiff.
11. Plaintiff’s Motion for Summary Judgment on Count II is GRANTED.
12. Defendant’s Motion for Summary Judgment is DENIED.Analysis
The court is well aware of the multitude of complex issues involving PIP. Exhaustion of benefits and priority of payments continue to be a source of much confusion. A plaintiff must be vigilant in ascertaining whether a deductible truly applies; whether it has been correctly applied to the bills in the order in which they were received; where its claims rest in relation to other claims submitted; whether benefits remain, and, if so, what bills have been submitted that are entitled to payment.
The nature of litigation in this area is such that a Plaintiff may well end up spinning its wheels needlessly if benefits have in fact been paid out properly and in full. In short, the only method of obtaining a verifiable objective answer to these issues is to obtain a PIP payout sheet; declarations page and a copy of the policy in effect. By requesting this information pre-suit, the Plaintiff is attempting to assess whether the filing of a lawsuit is warranted.
In this case, the Plaintiff waited for the insurance information it had requested from UNITRIN DIRECT PROPERTY & CASUALTY COMPANY before resorting to filing suit. The Defendant clearly had the ability to provide this information and simply chose not to do it. Many times in the past, information relayed by adjusters pre-suit has turned out to be incorrect once suit has been filed accordingly, actual PIP logs and declarations pages are needed to determine whether the bills were in fact subject to a deductible; whether benefits have in fact been exhausted; and the policy is needed to review the actual language that determines, with respect to out of state coverages, whether the policy contains language that would afford coverage in the state of Florida.
The law regarding a medical provider’s right to receive insurance documentation presuit has been resolved in the Eighteenth Judicial Circuit. Recently, in New Hampshire Indemnity Insurance Co. vs. Rural Metro Ambulance a/a/o William Zaniboni, Case No. 04-72-AP (18th Judicial Cir., Appellate Division, November 18, 2005) [13 Fla. L. Weekly Supp. 573a], a three judge circuit appellate panel found that Rural Metro “was entitled to the information and documentation requested pursuant to the assignment of benefits received from [an insured].” The court agreed with Rural Metro that it has a right to determine, pre suit, what claims have been made and when; if any claims have been paid or denied; whether the deductible has been met; and, if not, how much remains; and whether benefits have truly been exhausted. The court went on to say:
Whether such information is compiled in a PIP log or some other data compilation format is immaterial. For these same reasons, RMA has a right to a copy of the insurance policy and declarations page. Although a requirement to provide such information may not be expressly stated in Section 627.736, Florida Statutes, this Court finds that the provision of such information is essential to RMA’s ability to determine its status as a claimant and makes eminently good common sense. Furthermore, the Court finds that the provision of such information by an insurer to an insured, or its assignee, is consistent with the purpose of the no-fault statutory scheme, to wit: “to ‘provide swift and virtually automatic payment so that the injured insured may get on with his life without undue financial interruption.’ ” See Allstate v. Ivey Ins. Co., 774 So.2d 679, 683-684 (Fla. 2000) (quoting Government Employees Ins. Co. v. Gonzalez, 512 So.2d 269, 271 (Fla. 3d DCA 1987)). To hold otherwise would place providers in the untenable position of having to rely solely upon the explanation of the insurer without corresponding proof.
Moreover, this Court finds that RMA was entitled to the information and documentation requested pursuant to the assignment of benefits received from Zaniboni, which NHI did not contest below. Surely, Zaniboni had a contractual right to receive a copy of his insurance policy and declarations page any time he saw fit. Likewise, Zaniboni was entitled to know what claims had been made and paid; as well as the benefits remaining, if any, at a given point in time. By executing an assignment of benefits, RMA obtained all of the rights and benefits of Zaniboni under the policy including the right to obtain the requested documentation. See State Farm Fire and Casualty Co. v. Ray, 556 So. 2d 811, 812 (Fla. 5th DCA 1990) (citing Fla. Jur.2d, Assignments § 1 (1978) in defining an assignment as “. . . the act by which one person transfers to another, or causes to vest in another, his right of property or interest therein.”). [Emphasis added.]
Other recent appellate opinions from this jurisdiction have followed Zaniboni. See Progressive Express Insurance Co. v. Physical Medicine Group, a/a/o Audra Isaacson, Appeal No. 05-13-AP (18th Cir. Ct. Appellate Division May 11, 2006) [13 Fla. L. Weekly Supp. 972a] and Florida Emergency Physicians a/a/o William Eve v. American Vehicle Insurance Co., Appeal No. 05-60-AP (18th Judicial Circuit Ct. Appellate Division April 21, 2006). This Court has issued numerous rulings that an insured may file a declaratory judgment action in order to obtain insurance documentation.1 Other judges around the State of Florida have issued similar opinions.2
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1See e.g., Kelly Purvin v. Progressive Express Insurance Company, Case No.: 04-SC-3285 (Seminole Cty. Ct. February 8, 2005) (summary judgment was granted to the Plaintiff based on a pre-suit request for insurance documentation that was not provided); Florida Emergency Physicians Kang & Associates, M.D., P.A. a/a/o Dean Walker vs. Nationwide Mutual Fire Ins. Co., 12 Fla. L. Weekly Supp. 592a (Fla. Seminole Cty. Ct. 2005); Florida Emergency Physicians a/a/o Venton Brown vs. Nationwide Property & Casualty Ins. Co., 12 Fla. L. Weekly Supp. 505a (Fla. Seminole Cty. Ct. 2005); Florida Emergency Physicians Kang & Associates, M.D., P.A. a/a/o William Eve vs. American Vehicle Insurance Co., 12 Fla. L. Weekly Supp. 593a (Fla. Seminole Cty. 2005); The Stand-Up MRI of Orlando, P.A. a/a/o Francela Henry vs. OMHI Ins. Co., Case No. 04-SC-815 (Seminole Cty. Ct., January 23, 2006); Gary H. Weiss, D.C., DABFE a/a/o Daisy Rivera vs. Mercury Ins. Co. of FL, Case No. 05-CC-509 (Seminole Cty. Ct., January 23, 2006).
2Other trial level cases involving successful declaratory judgment actions for insurance documentation/information from PIP carriers include Rural Metro Ambulance (Aletha Bryant) v. Liberty Mutual Insurance Company, 11 Fla. L. Weekly Supp. 583a (Orange Cty. Ct. 2004) (Judge Leon Cheek III); Tallahassee MRI, P.A. (Jacques Amilcar) v. Progressive Auto Pro Insurance Company, 11 Fla. L. Weekly Supp. 69a (17th Jud. Cir. 2003) (Judge Steven Deluca); Marcus Laws vs. Florida Automobile Joint Underwriting, 12 Fla. L. Weekly Supp. 566a (Fla. Duval Cty. 2005); Primary Care Medical Group a/a/o Bermudez Eliczer vs. United Automobile Ins. Co., 12 Fla. L. Weekly Supp. 493a (Fla. Broward Cty. Ct. 2005); Greater Chiropractic Center Corp. a/a/o Gurvinder Ghandi vs. Alpha Property & Casualty Insurance Company, Case No. 05-SC-3559 (Orange Cty. Ct., November 4, 2005); Florida Emergency Physicians, Kang & Associates, M.D., P.A., a/a/o Darrell Mixon vs. Illinois National Insurance Company, Case No. 48-2004-SC-4734-O (Orange Cty. Ct., November 6, 2005) [13 Fla. L. Weekly Supp. 354b]; Florida Emergency Physicians Kang & Associates, M.D., P.A. a/a/o Stephanie Carrico vs. American Vehicle Insurance Company, 12 Fla. L. Weekly Supp. 478b (Fla. Orange Cty. 2005) (Judge Jerry L. Brewer); ROM Diagnostics v. Security National Insurance Company, 9 Fla. L. Weekly Supp. 323b (Fla. Orange County 2002) (Judge C. Jeffery Arnold); Integra Diagnostics a/a/o Shawn Umstead v. Reliance National Indemnity Company, 8 Fla. L. Weekly Supp. 394c (Fla. Broward Cty. Ct. 2001); Palm Beach Regional MRI, Inc. (Cynthia Jackman) v. Southern Group Indemnity, Inc., 11 Fla. L. Weekly Supp. 742a (Cty. Ct., 15th Jud. Cir. 2004).
