15 Fla. L. Weekly Supp. 155e
Insurance — Personal injury protection — Explanation of benefits — Failure to provide EOB within 30 days of receipt of medical bill breached contract
SPINE REHABILITATION CENTER, INC. (As Assignee of Manuel Baez), Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, County Civil Claims Division. Case No. 06-17263, Division I. October 27, 2007. Charlotte W. Anderson, Judge. Counsel: Timothy A. Patrick, Nicholas, Lipscomb & Patrick, P.A., Tampa, for Plaintiff. Elizabeth E. Andrews, Kingsford & Rock, P.A.; and Steven Manno, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT AS TO COUNT III
THIS CAUSE having come before the Court on October 9, 2007, on Plaintiff’s Motion for Partial Summary Judgment as to Count III of Plaintiff’s Second Amended Petition for Declaratory Judgment and Complaint. Present before the Court were Plaintiff’s counsel, Timothy A. Patrick, Esquire and Defendant’s counsel, Elizabeth Andrews, Esquire and Steven Manno, Esquire. The Court after reviewing the court file, having heard argument of counsel and after review of relevant legal authority, makes the following findings and ruling:
1. Count III of Plaintiff’s complaint is a breach of contract action that alleges that within thirty days of receipt of requests for medical reimbursement from the Plaintiff, the Defendant did not provide an itemized specification of each item that the insurer had reduced, omitted, or declined to pay pursuant to F.S. 627.736(4)(b). Plaintiff makes no claim for damages in Count III other than entitlement to attorney’s fees and costs.
2. The provisions of the Florida Statutes governing insurance become part of the insurance contract between the parties, and that accordingly, the provision of the Florida Statutes s. 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 is proper.
3. The court cites to South Florida Pain and Rehabilitation, P.A. (a/a/o Mary Brown) v. United Automobile Ins. Co., 13 Fla. L. Weekly Supp. 1098 (17th Circuit Court, Broward County, Case No. 06-0665 COSO 60 08/25/06).
4. F.S. 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.”
5. It is the court’s opinion that a plain reading of F.S. 627.736(4)(b) provides that if the insurer does not pay the claim within thirty (30) days, then it is rejecting the claim.
6. The Defendant cannot simply ignore the claim. It has an obligation to provide an explanation of benefit (EOB) to the medical provider within thirty days of receipt of the medical bill.
7. The court disagrees with Defendant’s assertion that because there was no partial payment or rejection of the medical provider’s bill within thirty (30) days of receipt of the bill, the insurer does not have an obligation to provide an explanation of its reason for non-payment of the claim within thirty (30) days.
8. The Defendant failed to comply with F.S. 627.736(4)(b) and breached its contract based upon its failure to provide explanations of benefits for dates of service 11/14/05 through 12/07/05 within thirty (30) days.
9. Plaintiff’s Motion for Partial Summary Judgment is HEREBY GRANTED. Summary judgment is entered in favor of Plaintiff as to Count III. Plaintiff is the prevailing party as to Count III.
10. The court reserves jurisdiction to determine Plaintiff’s entitlement to attorney’s fees and costs.
