15 Fla. L. Weekly Supp. 1204a
Insurance — Personal injury protection — Notice of loss — Claim form — Professional license number — Where there is no professional license required for MRI facility to perform or bill for MRI, insurer cannot refuse to pay timely presented claim for medically necessary MRI on ground that provider failed to list professional license number in box 31 of CMS-1500 claim form
OAKLAND PARK MRI, INC., Laura Colavito, Plaintiff, vs. UNITED SERVICES AUTOMOBILE ASSOCIATION, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 07-10051SP23 (4). September 11, 2008. Eric Wm. Hendon, Judge. Counsel: Harley N. Kane. Miriam Merlo.
ORDER GRANTING FINAL SUMMARY JUDGMENT FOR PLAINTIFF
This action was heard on August 25th, 2008 on the parties’ cross-motions for summary judgment. The court finds on the questions presented there are no disputed questions of fact and this case rests upon a pure question of law. Both sides were well represented by counsel. Upon consideration, it is ORDERED AND ADJUDGED that the Plaintiff’s motion for final summary judgment is GRANTED and the Defendant’s Motion for Final Summary Judgment is DENIED.
The Question Presented here is “May an insurer refuse to pay for a medically necessary MRI which was timely presented simply because it fails to list a “professional license number in box 31” of the CMS-1500 billing form where there is no professional license number issued to an MRI supplier?”
The Court answers that question in the negative. The CMS-1500 form submitted by the Plaintiff herein substantially complies with all requirements imposed by the no-fault act.
The Defendant argues that Oakland Park’s failure to include a “professional license number in box 31 on the CMS-1500 is fatal to the bill because it was not “properly completed” and therefore USAA was not on notice of the bill and therefore it is not payable. The Court finds that the claim of lack of notice is a legal fiction and that USAA had actual knowledge of the services rendered and if there were any questions or doubt regarding the validity of the testing or the licensure of either the plaintiff, the treating physician, or the interpreting radiologist — those questions have been resolved (either before or after suit). USAA does not question the licensure of any party involved herein. In addition, USAA admits the MRI is covered1; admits the MRI was medically necessary, admits the MRI was related to the motor vehicle accident, and admits other than “notice” because the CMS-1500 form was not “properly completed” [to USAA’s satisfaction] there are no other defenses to the payment of the MRI.
It is also undisputed that there is no professional license2 number granted or required of an MRI supplier. “Laws should he enforced with common sense and applied without losing sight of the legislative purpose behind their enactment. To do otherwise is to generate disrespect for the law by creating a morass of technical regulations with no connection to human experience.” Mackey v. Household Bank, F.S.B., 677 So.2d 1295 (Fla. 4th DCA 1996). It is clear that to allow a defendant not to pay its contractual obligations because of a technical regulation which is impossible for Oakland Park to comply with runs contrary to the purpose behind the no-fault law3. One such case which illustrates this point is Evans Packing Company v. Department of Agriculture and Consumer Services, 550 So.2d 112 (Fla. 1st DCA 1989). There the Court overturned an administrative conviction of an orange juice packing plant. The Court held:
if the act requires an impossible thing to be done, or something to be done in an impossible manner, the courts may declare it incapable of enforcement in a particular case, but that such fact does not invalidate the statute; “All statutes must receive a sensible construction, such as will effectuate the legislative intention, and, if possible, so as to avoid an unjust or an absurd conclusion.
Based upon the foregoing it is clear that USAA’s technical defense, which is impossible for Oakland Park to comply with, must fail. There is no “professional license” required of a MRI facility to perform or bill for an MRI scan. Since there is no “professional license” required there cannot be a “professional license number” to place in box 31. It is impossible to reconcile the overriding purpose of the no-fault statute with the plain language application USAA advocates. Such a construction thwarts the purpose of the no-fault statute: to provide swift, virtually automatic payment of automobile injuries without regard to fault. Oakland Park is entitled to be paid for the MRI in question at the appropriate statutory reimbursement.
The Defendant also raises additional defenses which the Court finds without merit. The Defendant claims that because the Plaintiff placed an expired registration number with the Department of Health that the CMS-1500 form is not properly completed and therefore USAA is not on notice of the claim. The Defendant claims that because the signature of a clerk working for a properly authorized billing company was placed in Box 31 that the CMS-1500 form is not properly completed and therefore USAA is not on notice of the claim. The Defendant claims that because the plaintiff’s medical director did not document his duties that the CMS-1500 form is somehow illegal and therefore USAA is not responsible for the claim. The Court rejects those defenses. The Court finds that the public policy of this state is to give effect to the purpose of the no-fault statute: the purpose of the no-fault statute: to provide swift, virtually automatic payment of automobile injuries without regard to fault. USAA’s position thwarts that purpose for no legitimate reason other than it does not want to pay.
The statutory amount due for this MRI is $1326.63 plus prejudgment interest from May 17th, 2006 which is $328.34 for a total judgment amount of $1654.97, for which let execution issue. The Court reserves ruling on the plaintiff’s motion for attorney fees and costs.
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1The Policy involved herein contains both No-Fault and Medical Payments Coverage with no deductibles. There are sufficient benefits available to cover this bill.
2USAA contends that Oakland Park possesses an AHCA license number, employed an interpreting radiologist to perform the professional component of the MRI and has a medical director who possesses a professional license. The court finds that the AHCA license is not a “professional license” and that neither interpreting radiologist nor the medical director is the “supplier” of the services.
3The Florida No-Fault Insurance Law, F.S.§627.736, was initially enacted in 1971 on the premise that in exchange for giving up their constitutional rights to pursue pain and suffering damages for nonpermanent injuries sustained in motor vehicle accidents the injured persons would be entitled to swift and prompt payment of claims for medically necessary and reasonable expenses incurred and for lost wage benefits. Ivey v. Allstate Ins. Co., 774 So.2d 679 (Fla.2000). That purpose has not changed. Warren v. State Farm Mutual Automobile Insurance Company, 899 So.2d 1090 (Fla. 2005).
