15 Fla. L. Weekly Supp. 744c
Insurance — Personal injury protection — Explanation of benefits — Summary judgment is entered in favor of medical provider as to count alleging breach of contract for failure to provide EOB
NDNC NEUROLOGICAL TREATMENT CENTERS, INC. (a/a/o Yves Derival) vs. UNITED AUTOMOBILE INSURANCE COMPANY. County Court, 17th Judicial Circuit in and for Broward County. Case No. 07-6597 COCE (52). February 7, 2008. Jay S. Spechler, Judge. Counsel: Emilio R. Stillo, South Florida Trial Lawyers LLC, Sunrise. Verna Popo, Office of the General Counsel, United Automobile Insurance Company.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT II OF PLAINTIFF’S COMPLAINT (BREACH OF CONTRACT SEEKING ITEMIZED SPECIFICATION OF UNPAID CHARGES/EOB)
THIS CAUSE came before the Court on February 2, 2008 for hearing on Plaintiff’s Motion for Summary Judgment (Count II — Breach of Contract seeking itemized specification of unpaid charges/EOB), 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 as follows:
Background. On or about April 26, 2007, having not received from Defendant the required statement of the reasons for non-payment of its charges, the Plaintiff filed its Complaint against the Defendant for Breach of Contract seeking an itemized specification of unpaid charges/Explanation of Benefits itemizing the charges received by Defendant from Plaintiff and detailing the reasons for nonpayment. The gist of Count II is that the Defendant failed to provide the explanation of benefits required by Florida Statute § 627.736(4)(b).
Defendant has presented no record evidence showing that it furnished the itemized specification within 30 days of receipt of the medical bills.
In fact, Defendant’s own adjuster testified in deposition as follows:
Q: So it’s fair to say that the Defendant did not furnish an itemized specification of benefits?
A: Correct.
Conclusions of Law. As pertains to the issue in this Motion, Florida Statute § 627.736(4)(b) provides: “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 and any information that the insurer desires the claimant to consider related to the medical necessity of the denied treatment or to explain the reasonableness of the reduced charge, [. . .]; and the insurer shall include the name and address of the person to whom the claimant should respond and a claim number to be referenced in future correspondence” (emphasis added). This is generally informally referred to as an “explanation of benefits.”
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), and that accordingly, the provision of Florida Statute § 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 e.g. United Automobile Ins. Co. v. R.J. Trapana, M.D. P.A., 12 Fla. L. Weekly Supp. 452 (Decision of Judge Richard Eade, Circuit Court, Broward County in its appellate capacity 2005); United Automobile Insurance Co. v. Stat Technologies, Inc. 13 Fla. L. Weekly Supp. 37c (Decision of Judge John Luzzo, Circuit Court, Broward County, in its appellate capacity 2005); Fidel S. Goldson, D.C. P.A. (a/a/o Jon Gray) v. United Automobile Insurance Company, 12 Fla. L. Weekly Supp. 161b, (17th Judicial Circuit 2004, Hon. Robert W. Lee). As a result, Defendant was obligated to furnish Plaintiff with an itemized specification of the unpaid charges and the reasons for non-payment. The policy is sound (avoiding needless litigation and fostering open communication regarding claims submissions). It is also expressly mandated by the statute. An insurer that fails to provide the explanation of benefits within 30 days of receipt of the medical bills is in breach of contract. Spine Rehabilitation Center, Inc. (a/a/o Manuel Baez) v. State Farm Mutual Automobile Insurance Company, 15 Fla. L. Weekly Supp. 155e (13th Judicial Circuit 2007, Hon. Charlotte W. Anderson).
ORDERED AND ADJUDGED THAT: the Plaintiff’s Motion for Summary Judgment is GRANTED in favor of Plaintiff as to Count II of the Complaint as to liability and at a minimum nominal damages. As to Count II, Plaintiff is the prevailing party. Pursuant to Florida Statute 627.428, Plaintiff is entitled to recover from Defendant attorney’s fees and costs as to this Count in an amount to be determined at a later hearing, for which, the Court reserves jurisdiction.
