16 Fla. L. Weekly Supp. 17b
NOT FINAL VERSION OF OPINION
Subsequent Changes at 16 Fla. L. Weekly Supp. 503a
Insurance — Personal injury protection — Coverage — Withdrawal of benefits — Retroactive notice of withdrawal — Insurer was required to provide notice of termination of benefits to insured and medical provider — Where insured continued receiving medical treatment from provider in two-week period between independent medical examination and receipt of notice of termination of benefits effective on date of IME, and neither insured nor provider made attempt to contact insurer to determine results of IME, there is genuine issue of material fact as to whether notification was sent in reasonable time and whether medical treatment rendered after IME was reasonable, related and necessary — Error to enter summary judgment in favor of provider
UNITED AUTOMOBILE INSURANCE COMPANY, Appellant, vs. MARRUCCI WELLNESS CENTERS, LLC., a/a/o Haraman Sila, Appellee. Circuit Court, 11th Judicial Circuit (Appellate) in and for Miami-Dade County. Case No. 07-191 AP. L.C. Case No. 05-1300 CC 26 (02). November 18, 2008. An Appeal from the County Court for Miami-Dade County. Counsel: Lara J. Edelstein, Office of the General Counsel/Trial Division, United Automobile Insurance Company, for Appellant. Mari Sampedro-Iglesia, Jose R. Iglesia & Associates, Inc., for Appellee.
(Before SCOTT J. SILVERMAN, DARYL E. TRAWICK, and KEVIN M. EMAS, JJ.)
(Trawick, Daryl E., J.) Appellee Marrucci Wellness Center, LLC (“Marrucci” or the provider) is a medical provider that rendered care and treatment to Havaman Sila, a non-party who was injured in an automobile accident which occurred on January 17, 2004. At the time of the accident, Sila was insured for personal injury protection coverage by Appellant, United Automobile Insurance Company (“United Auto”).
Sometime after Sila had begun receiving medical care from the provider, United Auto arranged for Sila to submit to physical examination by Dr. Luis Castillo, a doctor selected by Appellant, to determine the need for future treatment of Sila. Dr. Castillo examined Sila on March 10, 2004, and he concluded that all treatment to date had been reasonable, related and necessary, but that no further medical treatment would be required. United Auto generated a letter two weeks later (March 25, 2004), saying it was not providing coverage for medical treatment rendered after March 10. During the two week period between the medical examination (IME) and the time the provider received the letter from United Auto, the provider continued to provide treatment to Sila. The provider won summary judgment in the lower tribunal on the issue of United Auto’s failure to satisfy a prerequisite component of the statutory IME withdrawal defense when it gave retroactive notice to the provider of the termination of benefits. United Auto filed this appeal, arguing that summary judgment for the provider was inappropriate because any treatment given after March 10 was not reasonable, related, or necessary.
Summary judgment is a procedural device for disposition of actions in which there are no genuine issues as to any material fact and where the moving party is entitled to judgment as a matter of law. Fla. R. Civ. P. 1.510; Stringfellow v. State Farm Fire & Casualty Co., 295 So. 2d 686 (Fla. 2d DCA 1974).
The issue presented here is whether the actions of United Auto raised any genuine issue of material fact. Specifically, we must determine if the notification letter sent by United Auto to Sila and Marrucci was required by law. If so, we must then determine whether the manner in which the notification letter was sent raises any genuine issue of material fact.
United Auto contends that they are under no legal obligation to send a notification of the termination of benefits to the insured or to the provider. However, F.S. §627.736(10)(b)(3), (Fla. 2008) which discusses the pre-requisites for the commencement of an action for benefits against an insurer, states in pertinent part:
To the extent that the demand involves an insurer’s withdrawal of payment under para (7)(a) for future treatment not yet rendered, the claimant shall attach a copy of the insurer’s notice withdrawing such payment . . . .
Since a claimant must attach a copy of the notice of termination of benefits received from the insurer, a fortiori, the insurer is required to provide such a notification to the claimant. Thus, contrary to the position of United Auto, they were under a legal obligation to provide the notice at issue here.
Did United Auto send the required notification of the termination of benefits to Sila and/or Marrucci in a reasonable and timely manner? The insured continued receiving medical treatment from the provider after the IME, even going for an appointment the very next day. Neither the insured nor the provider made the effort to contact the insurer to find out what the results of the IME were, or what the preliminary report of Dr. Castillo had been. The actual notification was not provided by United Auto until two weeks after the IME. We conclude that these facts raise a genuine issue of material fact as to whether the notification was sent in a reasonable time, and whether medical treatments rendered after the March 10 IME were reasonable, related, or necessary. As such, we reverse the lower tribunal, and remand this matter to that court for a determination of reasonable attorney’s fees for the Appellant. (Judges Silverman and Emas concur.)
