16 Fla. L. Weekly Supp. 470a
Online Reference: FLWSUPP 165PEMBR
Insurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Where there was no bad faith on part of insurer, insurer was not required to reserve benefits to pay bill which was denied due to incomplete claim form
PEMBROKE PINES MRI, INC., Wendy Brigante, Plaintiff, v. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County, Civil Division. Case No. 08-175 COCE 54. February 27, 2009. Lisa G. Trachman, Judge. Counsel: Harley N. Kane. Miriam R. Merlo, Law Offices Gaebe, Mullen, Antonelli, Esco & DiMatteo, Coral Gables, for Defendant.
ORDER AND FINAL JUDGMENT ON DEFENDANT’S MOTION FOR SUMMARY JUDGMENT ON BENEFITS EXHAUSTED ISSUE
This case was heard on February 19, 2009, on the motion of Defendant for summary judgment on the benefits exhausted issue. After a review of the pleadings and filings, hearing argument of counsel, and being otherwise advised in the premises, it is hereupon
ORDERED AND ADJUDGED that Defendant’s motion for summary judgment on the issue of benefits exhausted is granted.
The Court makes the following factual Findings. Plaintiff, a provider of MRI services, submitted a CMS-1500 form to the Defendant for two MRI services. The CMS-1500 form was a global bill which included charges for the technical and professional components. Plaintiff did not include a professional license number in Box 31 of the CMS-1500 form. Defendant denied payment of the bill based upon its position in its Explanation of Reimbursement (EOR) which states that “CMS 1500 form needs to be submitted with Box 31 completed pursuant to Florida PIP Statute 627.736. Box 31 should contain the name of the provider or supplier who rendered the service and their professional license number.” Subsequent to the receipt of Plaintiff’s bills Defendant received additional bills which were paid and which exhausted the PIP benefits.
Pursuant to Progressive American Insurance Co. v. Stand-up MRI of Orlando, 990 So.2d 3 (Fla. 5th DCA 2008) and Simon v. Progressive Express Ins. Co., 904 So.2d 449 (Fla. 4th DCA 2005), the Court finds no bad faith on the part of this Defendant which might require the insurance company to set aside disputed amounts. As noted in Stand-up MRI, supra,“. . . The Defendant did nothing wrong here. They were under a contract to the insured for a limited amount of benefits. They paid that amount in toto. They are not responsible for the insured’s over-use of this policy. The Defendant did not gain anything out of their actions. They fully performed their contract with the insured. It is to the insured that the assignees should look for any additional payments.”
Because this issue is dispositive of the entire case, final summary judgment is entered in favor of Defendant and against the Plaintiff.
The Court reserves jurisdiction to award attorney fees and costs, if appropriate.
[Editor’s note: see 16 Fla. L. Weekly Supp. 864b.]
