16 Fla. L. Weekly Supp. 682a
Online Reference: FLWSUPP 167SALGA
Insurance — Personal injury protection — Explanation of benefits — Letter which suspended benefits due to independent medical examination and stated that some or all charges were not reasonable, but which did not identify which specific charges were not reasonable and did not itemize each charge received and identify why it was not paid, was not legally compliant EOB
ADVANCE HEALTH CENTER, INC., a Florida Corporation (assignee of Salgado, Otilia), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 09-03123 COCE 51. May 19, 2009. Martin R. Dishowitz, Judge. Counsel: Russel Lazega, Law Office of Russel Lazega, P.A., North Miami, for Plaintiff. Matt Hellman, Matt Hellman, P.A., Plantation, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT
(COUNTFOR BREACH OF CONTRACT RE: ITEMIZEDSPECIFICATION OF CHARGES)
THIS CAUSE came before the Court on hearing on Plaintiff’s Motion for Summary Judgment as to Count I (Breach of Contract regarding itemized specification of unpaid charges), 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:This is a multi-count P.I.P. case. Count I of Plaintiff’s Complaint pleads that Defendant breached its insurance contract by failing to provide Plaintiff with a legally compliant “itemized specification” of the unpaid charges (commonly known as an “Explanation of Benefits” or “EOB”) and that failure to comply with this statutory obligation amounts to a breach of contract and entitling Plaintiff to recover damages as well as attorney’s fees and costs related to the action to enforce this statutory obligation. The response in question from the insurer contained a letter indicating an IME suspension of benefits roughly mid-way into treatment and stating that some or all of the charges were not reasonable. The letter did not identify which specific charges were allegedly unreasonable and was accompanied by a no-fault payment log which listed a range of services but likewise did not itemize each specific charge received and why it was not paid.
Conclusions of Law:It is well-settled in this circuit that “insurer’s obligation to provide an itemized specification is clear. §627.736(4)(b), Fla. Stat.” United Auto. Ins. Co. v. R.J. Trapana, M.D., P.A.,12 Fla. L. Weekly Supp. 452a (17th Jud. Cir. Appellate 2005) and that “failure to provide the required specification result[s] in a breach of its obligation, entitling [the claimant] to attorney’s fees and costs. §627.428(1)”, Id.
The court finds that the breach is material and Plaintiff has met the requisite burden to show that Defendant did not furnish Plaintiff with a legally compliant EOB at the time of denial. Specifically, the Defendant’s response is not itemized as to each code billed nor does it indicate the reasons for non-payment for each specific code such that the person reading the response can determine which specific codes were denied, which were reduced (including by how much) and why. As such Defendant failed to provide an EOB for all services and
Accordingly, it is hereby ORDERED that Plaintiff’s Motion for Partial Summary Judgment with regard to Count I is GRANTED as follows: 1) Plaintiff is entitled to summary judgment as to liability related to the EOB claim as well as 2) damages (at a minimum nominal damages) and 3) reasonable attorney’s fees and costs related to this count pursuant to F.S. s. 627.428.
