17 Fla. L. Weekly Supp. 382b
Online Reference: FLWSUPP 1705FORG
Insurance — Personal injury protection — Delay in payment — Request for information or documentation — Sufficiency — Non-specific statement printed on each explanation of benefits inviting medical provider to submit whatever documentation or information provider would guess is necessary in response to insurer’s rejection of claim was insufficient to demand additional documentation needed to process claim and toll time for payment of claim
RUSSELL E. TURNER, D.C., PLLC, a Florida Corporation (assignee of Forgue, Cresha), Plaintiff, v. STATE FARM FIRE AND CASUALTY COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 09-22630 CC 23 (2). March 2, 2010. Caryn Canner-Schwartz, Judge. Counsel: Law Office of Russel Lazega, North Miami. Matt Hellman, P.A., Plantation.
AMENDED ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT AND DENYING DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT
THIS CAUSE, came before the court for hearing on Plaintiff’s and Defendant’s respective Motions for Summary Judgment on January 5, 2010, and the court, having reviewed the Motions, the court file, legal authorities and having heard argument of counsel, finds as follows:
Factual Background: This is a P.I.P. suit. The parties move for summary judgment on the Defendant’s defense, which alleges that Plaintiff has failed to provide additional medical records and documentation in response to requests made by Defendant pursuant to F.S. s. 627.736(6)(b), and as such, Plaintiff’s claim is not yet overdue.
Defendant’s F.S. s. 627.736(6)(b) request, printed at the bottom of every explanation of review submitted by Defendant to Plaintiff, reads as follows:
Pursuant to F.S. s. 627.736(6)(b), should you have any information to substantiate payment of an additional amount for the services rendered, please forward for consideration.
Plaintiff maintains 1) that Defendant was provided all necessary information to process the claim and substantiate payment as the billing submission included notes and reports of the medical treatments rendered and 2) that Defendant’s alleged F.S. s. 627.736(6)(b) request was insufficient and not specific as it failed to apprise the Plaintiff of what additional information was needed in order to process the claim. Defendant maintains that its F.S. s. 627.736(6)(b) request was specific and sufficient to apprise Plaintiff of what additional information was being requested.
Conclusions of Law: This court finds that Defendant’s alleged F.S. s. 627.736(6)(b) request for additional information made in its explanation of review was insufficient as it was vague and failed to place the Plaintiff on notice of what information/documentation was being requested or for what code.
The Defendant’s non-specific, generic, automatic printed F.S. s. 627.736(6)(b) request, essentially, invites the Plaintiff to submit whatever documentation or information Plaintiff would guess would be necessary in response to Defendant’s rejection of the claim.
Accordingly, it is hereby:
ORDERED AND ADJUDGED that Plaintiff’s Motion for Partial Summary Judgment is GRANTED and Defendant’s Motion for Final Summary Judgment is DENIED. Summary Judgment for Plaintiff is granted as to affirmative defense #2 (additional information requested) and granted in part as to the second sentence of Defendant’s affirmative defense #4 (invalid/premature demand letter). This Court reserves jurisdiction to consider Plaintiff’s motion for attorney’s fees under F.S. s. 57.105 at a later date.
