15 Fla. L. Weekly Supp. 949b
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., Tyesean Tillmon, Plaintiff, vs. UNITED SERVICES AUTOMOBILE ASSOCIATION, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 07-12692-COCE (55). July 11, 2008. Sharon L. Zeller, Judge. Counsel: Harley N. Kane, Kane & Kane, Boca Raton. Miriam Merlo, Coral Gables.
ORDER GRANTING FINAL SUMMARY JUDGMENT FOR PLAINTIFF
This action was heard on May 20th, 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 Presented1 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 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. USAA admits the MRI is covered; admits the MRI was medically necessary, admits the MRI was related to the motor vehicle accident, and admits other than “notice” and the failure to be “properly completed” 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 be 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 statutory amount due for this MRI is $1005.97 plus prejudgment interest from January 4th, 2007 which is $164.62 for a total judgment amount of $1280.59, for which let execution issue. The Court reserves ruling on the plaintiff’s motion for attorney fees and costs.
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1The Defendant also raises an issue related to whether an employee of a billing company may sign in Box 31 on behalf of the plaintiff on the CMS-1500 form. The Plaintiff argues that this issue was not raised by the Defendant in its explanation of benefits, in its response to the demand letter, or in its answer and affirmative defenses in this suit. The Court finds the defendant has waived this issue because legal issues not raised in pleadings are deemed waived and may be tried only with the express or implied consent of the parties. City of Fort Walton Beach v. Grant, 544 So.2d 230 (Fla. 1st DCA 1989) citing Hart Properties, Inc. v. Slack, 159 So.2d 236 (Fla.1964); Bilow v. Benoit, 519 So.2d 1114 (Fla. 1st DCA 1988); Fla.R.Civ.P. 1.140(b), (h); 1.190(b).
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).
