15 Fla. L. Weekly Supp. 1188a
Insurance — Personal injury protection — Demand letter — Medical provider that continued to provide treatment to insured after insurer withdrew benefits was not required to furnish written plan for additional treatment to insurer as condition precedent to serving demand letter and filing suit — Medical provider had option to simply continue treatment with risk of nonpayment or attempt to gain insurer’s concession to continued coverage through treatment plan
DR. ELLIS SCHAUDER d/b/a SCHAUDER CHIROPRACTIC CARE, as assignee of Helen Rosario-Soto, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 2006-SC-2105-O. June 27, 2008. Antoinette Plogstedt, Judge. Counsel: Peter Shapiro, Orlando. John Morrow, Orlando.
ORDER
THIS CAUSE having come on for a hearing on Defendant’s Motion for Partial Summary Judgment as to its affirmative defense and Plaintiff’s Motion for Partial Summary Judgment and the Court having reviewed the court file and being otherwise duly advised in the premises, it is hereby
ORDERED and ADJUDGED that the Defendant’s Motion for Partial Summary Judgment is hereby DENIED and Plaintiff’s Motion for Partial Summary Judgment is hereby Granted. The Court further finds, as follows:
1. That Plaintiff has filed a cause of action against Defendant for breach of contract.
2. That Defendant issued a policy of insurance to the insured for medical payments coverage.
3. That it is undisputed that the insured suffered a loss, sought treatment with the Plaintiff as a result of said loss, and Defendant has provided coverage.
4. That pursuant to the terms of the policy, Defendant has caused the insured to undergo an independent medical examination (hereinafter “IME”).
5. That the independent professional rendered an opinion that additional treatment would no longer be reasonable, necessary, or related to the loss, as the insured had reached maximum medical improvement (hereinafter “MMI”).
6. That the Plaintiff continued to provide treatment to the insured.
7. That the Defendant has refused to pay Plaintiff for services rendered after the insured reached MMI.
8. That the Plaintiff issued a proper 15 day pre-suit demand letter to the Defendant. Defendant refused payment and the Plaintiff filed the instant action.
9. That the Defendant has filed an affirmative defense alleging that under Chapter 627 and under the terms of the contract, the Plaintiff failed to comply with a condition precedent to filing this cause.
10. The Defendant more specifically alleges that when the Defendant refused to pay for the insured’s continued treatment with the Plaintiff, Plaintiff was required to provide Defendant with a written plan for the insured’s proposed future treatment with the Plaintiff. The Defendant would then have 15 days to concede to pay for the outlined continued treatment to the insured with this Plaintiff or deny the same. Defendant alleges that since Plaintiff failed to provide Defendant with a proposed future treatment plan and an opportunity to agree to pay for the same, Plaintiff may not now file this cause of action for services performed.
11. Florida Statutes, Section 627.736(11), provides the specifications for the Plaintiff’s pre-suit demand letter. Pursuant to Florida Statutes, Section 627.736(11)(d), in response to a demand letter, when an insurer withdraws payment under (7)(a) for future treatment, the insurer may furnish a written statement of its agreement to then pay for such future treatment.
12. Chapter 627 is clear and unambiguous. In section 627.736(11), the legislature clearly enacted the requirements of the pre-suit demand letter for payment of treatment rendered. The legislature also provided an option for an insured to file suit when benefits have been terminated after an independent examination and further treatment not yet rendered. It further described the pre-suit demand letter process for said action.
13. However, the legislature did not intend to mandate that a provider furnish a written treatment plan when benefits have been cut off.
The provider may simply continue to provide services with the risk of non-payment by the insurer or may attempt to gain the insurer’s concession to continued coverage by furnishing a treatment plan.
14. In the instant action, Plaintiff has complied with the legislature’s intent by properly serving a pre-suit 15 day demand letter.
