18 Fla. L. Weekly Supp. 335a

Online Reference: FLWSUPP 1804DESA Insurance — Personal injury protection — Coverage — Notice of loss — Where medical provider was informed that patient did not have vehicle or insurance but might have coverage under mother’s PIP policy, and provider filed claim within 35 days of receipt of correct name and address of mother’s insurer, bills were payable — Error to impose on provider requirement to investigate patient’s insurance — Requirement that provider submit denial letter from incorrect insurer or proof of mailing showing timely mailing to incorrect insurer applies only when patient provides incorrect insurance information, not when patient mistakenly claims to have no coverage

CHARLIE DESAUSSURE, III, Appellant, vs DIRECT GENERAL INSURANCE COMPANY, Appellee. Circuit Court, 7th Judicial Circuit (Appellate) in and for Volusia County. Case No. 2010-10018-APCC. L.C. Case No. 2009-20141-CONS. February 11, 2011. Counsel: Luis R. Gracia, Rue & Ziffra, P.A., Port Orange, for Appellant. Patrick D. Hinchey, Vernis & Bowling of Central Florida, P.A., Deland, for Appellee.

[County court order at 17 Fla. L. Weekly Supp. 821a.]

OPINION

(PERKINS and HUDSON, JJ.) Appellant appeals from a Judgment entered in favor of the PIP Insurer denying payment of medical bills to the medical provider and, for the reasons discussed below, we reverse.

On October 5, 2007, the Appellant, Charles Desaussure III, (“Desaussure”) was injured in an automobile accident. He did not own a car and did not have automobile insurance. However, he lived with his mother and she did have insurance on her car through Direct General Insurance Company.

On October 9, 2008, Desaussure went to All Family Medical Clinic of Daytona Beach d/b/a Medical Associates (“AFM”) for medical treatment of his injuries. When asked specifically about PIP insurance, Desaussure told AFM he did not own a vehicle and did not have any insurance coverage. Nevertheless, AFM started medical treatment that day. Later that same day, AFM contacted Desaussure’s counsel and they in turn confirmed that Desaussure did not have insurance but added that he lived with his mother and that she might have PIP coverage through her policy.

It is undisputed that AFM did not learn of the existence of PIP coverage and the correct name and address of the PIP Carrier, Direct General, until February 11, 2008. On February 15, 2008, 4 days after learning of the coverage, AFC submitted their bills for treatment to Direct General. Direct General denied payment of the bills contending that the bills were submitted more than 35 days after treatment and were therefore not payable from the PIP coverage.

Desaussure sued Direct General for payment of the bills. Direct General moved for Summary Judgment and the trial court granted Direct’s Motion. The court found that the provider was told within a few days of starting treatment that Desaussure might have PIP coverage through his mother’s policy and as a result of that knowledge “it was the responsibility of the provider, having knowledge of the 35 day deadline, to make the appropriate investigation to determine if there was coverage.” Consistent with this ruling, the court entered Judgment in favor of Direct General on July 15, 2010 and this appeal timely followed.

Florida law provides that a PIP insurer is not required to pay medical bills postmarked more than 35 days after treatment is rendered. §627.736(5)(c)1, Fla. Stat. (2008). It is undisputed that AFM’s bills were not submitted to the insurer within 35 days of treatment. Accordingly, such bills are not payable by Direct General unless the provider met one or more of the various exception found in the statute.

Section 5(c)2 creates an exception to the 35 day rule and provides:

“If, however, the insured fails to furnish the provider with the correct name and address of the insured’s personal injury protection insurer, the provider has 35 days from the date the provider obtains the correct information to furnish the insurer with a statement of the charges.”

In this case, the evidence was undisputed that AFC did not receive the correct name and address of the insurer until February 11, 2008. But, once they did, they timely submitted their bills on February 15, 2008, clearly within 35 days of receiving Direct General’s correct name and address. Accordingly, AFC was entitled to payment of its bills.

The trial court correctly observed that AFC was told that their patient“might have PIP coverage through his mother’s policy” but the court incorrectly imposed a requirement on AFC to investigate Desaussure’s insurance. Specifically, the court held that:

“it was the responsibility of the provider, having knowledge of the 35 day deadline, to make the appropriate investigation to determine if there was coverage.”

No such discovery or investigation requirement can be found under a plain reading of the PIP statute. A provider need only bill the PIP insurer within 35 days of receiving the “correct name and address of the insured’s personal injury protection insurer”. The statute does not require that the provider investigate the patient’s coverage. Moreover, such a requirement would seem at odds with the purpose of the statute. The intent of the statute is to provide direct billing and speedy payment between provider and insurer and not to encourage the filing of mistaken or incorrect claims. See, Warren v. State Farm Mutual Automobile Ins. Co., 899 So.2d 1090 (Fla. 2005) [30 Fla. L. Weekly S197b]. Here, AFC did not receive the correct name and address of the PIP carrier, Direct General, until February 11, 2008, timely submitted those bills on February 15, 2008, and as a result, such bills were properly payable.

Direct General claims that AFC does not qualify for the exception to the 35 day rule because the statute requires that AFC also show that “the provider reasonably relied on erroneous information”¹ and that they submit with their bill either “a denial letter from the incorrect insurer” or “proof of mailing. . . reflecting timely mailing to the incorrect address or insurer.” See, §627.736(5)(c)2(a)(b). Direct General’s contention is not supported by the record for two reasons. First, the Trial Court specifically found that the requirements of 2(a) and 2(b) are “not applicable when the patient (insured) provides no information or advises the provider that they do not have any PIP insurance”. Direct General did not cross appeal the court’s holding.

Second, the rules of statutory construction renounce the insurer’s position. The requirement of 2(a) and 2(b) only apply, by their plain language, where the patient provides incorrect insurance information to the provider. Where, as here, the patient mistakenly claims to have no coverage, the statutory requirement of 2(a) or 2(b) do not apply. “A statute should be given a reasonable interpretation.” Johnson v. Presbyterian Homes of the Synod of Florida, 239 So.2d 256 (Fla. 1970). “It is well established in Florida that statutes, even where clear, should not be interpreted to produce absurd results”. Johnson v. Beary, 665 So.2d 334 (Fla. 5th DCA 1995) [21 Fla. L. Weekly D30a] and Orthopaedic Clinic of Daytona Beach, P.A. v. USAA Casualty Insurance Co., 16FLWSupp 1158b (Fla. 7th Cir. Volusia County, Oct. 1, 2009). As aptly stated by Judge Warren in Orthopaedic Clinic: “It seems incongruous that the PIP statute would allow providers with the wrong insurance information to still be able to be paid for their services even after the original time period to submit bills has elapsed but providers that are mistakenly given no insurance information at all are precluded from billing.” Id. at 1161.

Based on the above findings and holding, the Judgment entered by the court on July 15 2010 is hereby REVERSED and this cause is REMANDED back to the trial court for proceedings consistent with this decision.

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¹The evidence shows that the provider submitted with their billing “two computer printouts containing [FMC’s] actual office notes documenting inquiries into the matter of PIP insurance for Mr. Desaussure” and a “Request for Payment” form showing a blank space where the PIP claim or policy number should be written, evidencing their lack of the correct name and address of the PIP carrier. This Court is unable to determine from the record before us whether such uncontested submissions raise a question of fact preventing Summary Judgment on the issue of reasonable reliance but our holding here makes such analysis unnecessary.