16 Fla. L. Weekly Supp. 1061c
Online Reference: FLWSUPP 1611LAGE
Insurance — Personal injury protection — Notice of loss — Claim form — Medical provider that failed to include professional license number on CMS 1500 forms failed to put insurer on notice of covered loss — Provider cannot recover for resubmitted claim forms that were corrected to include professional license number where forms were untimely submitted more than 35 days after dates of service
REVERSED. 18 Fla. L. Weekly Supp. 140a.
TARPON TOTAL HEALTH CARE a/a/o MARGARET LAGE, Plaintiff, v. GEICO GENERAL INSURANCE COMPANY, Defendant. County Court, 6th Judicial Circuit in and for Pinellas County, Civil Division. Case No. 07-8666-CO-41. July 17, 2009. Myra S. McNary, Judge. Counsel: Arthur Liebling, Arthur Liebling, P.A., Safety Harbor, for Plaintiff. Robert H. Peterson, Masten, Lyerly, Peterson & Denbo, LLC, Tampa, for Defendant.
FINAL JUDGMENT FOR DEFENDANT
THIS CAUSE was heard on May 28, 2009, upon Defendant, GEICO GENERAL INSURANCE COMPANY’s (hereinafter “GEICO GENERAL”) Motion for Summary Judgment, and the Court having considered the evidence, reviewed the pleadings, considered argument of counsel and otherwise being fully advised, the Court finds as follows:Undisputed Material Facts
1. As evidence in support of its Motion for Summary Judgment, GEICO GENERAL submitted the Affidavit of Rebecca Schatzow, Continuing Unit Claims Examiner, Personal Injury Protection Litigation.
2. The material facts provided in Mrs. Schatzow’s Affidavit are
undisputed.
3. This claim arose from a January 14, 2000 auto accident with resulting injuries to GEICO GENERAL’s insured, Margaret Lage.
4. Mrs. Lage received medical treatment from Plaintiff, TARPON TOTAL HEALTH CARE (hereinafter “TARPON TOTAL”).
5. TARPON TOTAL timely submitted CMS 1500 (“bills”) to GEICO GENERAL for reimbursement under Mrs. Lage’s PIP benefit for dates of service: November 24, 2004 through December 22, 2004.
6. TARPON TOTAL’s bills failed to include the professional license number for any individual who provided the medical services indicated.
7. GEICO GENERAL denied reimbursement of the bills.
8. On July 9, 2007, GEICO received another set of bills submitted by TARPON TOTAL for the same dates and services previously billed.
9. The July 9, 2007 set of bills were corrected to include the professional license number in box 31.Legal Analysis and Ruling
10. Based on two separate legal theories, GEICO GENERAL’s Motion for Summary Judgment argues that both the first and second sets of TARPON TOTAL’s bills are non-compensable under the PIP Statute.
11. As to the first set of bills submitted, the Court agrees with GEICO GENERAL.
12. Although the bills were timely submitted within 35 days from the dates of service, they are fatally flawed because the bills failed to include a professional license number. A medical provider that does not supply the professional license number of the provider in box #31 on the submitted CMS 1500 form fails to meet the statutory requirements of §627.736(5)(d) and fails to put the insurer on noticed of covered loss as required by paragraph §627.736(4)(b). The Aries Ins. Co. v. First Chiropractic Clinic, Inc. a/a/o Yvette Orneus, 12 Fla. L. Weekly Supp. 637a (Fla. 13th Jud. Cir. App. April 25, 2005); New Life Polyclinics, Inc. v. U.S. Security Ins. Co., 14 Fla. L. Weekly Supp. 480c (Fla. 11th Jud. Cir. February 16, 2007); Hope Health & Wellness v. GEICO General Ins. Co., 14 Fla. L. Weekly Supp. 292a (Fla. 15th Jud. Cir. July 28, 2006).
13. As to the second set of bills submitted, the Court again agrees with GEICO GENERAL.
14. Although the bills included the professional license number on resubmission, they are fatally flawed because of their untimely submission more than 35 days after the dates of service. §627.736(5)(c)(1) Fla. Stat. (2007); United Auto Ins. Co. v. Garrido, 990 So. 2d 574 (Fla. 3rd DCA 2008); Altamonte Springs Imaging d/b/a Mid Florida Imaging v. USAA Casualty Ins. Co., 16 Fla. L. Weekly Supp. 575c (Fla. 9th Jud. Cir. April 23, 2009).
15. TARPON TOTAL may not recover PIP benefits for untimely submitted bills that were corrected to include previously omitted material information (i.e., professional license number).
16. Accordingly, IT IS HEREBY ORDERED and ADJUDGED that Defendant, GEICO GENERAL’s Motion for Final Summary Judgment is hereby GRANTED. Plaintiff shall take nothing by this action and the Court shall retain jurisdiction to determine GEICO GENERAL’s entitlement to reasonable attorney’s fees and costs. A Final Summary Judgment for Defendant is hereby awarded.
