18 Fla. L. Weekly Supp. 558a
Online Reference: FLWSUPP 1806GGAR
Insurance — Personal injury protection — Notice of loss — Claim form — Professional license number — Where insurer’s only basis for denying claim was failure of MRI provider to provide professional license number on claim form and case was stayed pending outcome of appellate case in which court held that MRI provider is not required to supply professional license number on claim form, retroactive application of appellate decision results in finding that insurer had no reasonable proof that it was not responsible for claim and is, therefore, liable for claim despite intervening exhaustion of all but $14 in benefits
PEMBROKE PINES MRI, INC., (a/a/o GABRIEL GARCIA), Plaintiff, vs. GARRISON PROPERTY AND CASUALTY INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 09-10942 COCE 55. March 22, 2011. Sharon L. Zeller, Judge.
ORDER ON DEFENDANT GARRISON PROPERTYAND CASUALTY INSURANCE COMPANY’S MOTIONFOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on February 7, 2011, for hearing of the defendant’s motion for final summary judgment, and the Court having reviewed the same, having heard argument of counsel, and being otherwise fully advised in premises, finds and decides as follows:
Plaintiff, a provider of MRI services, submitted a CMS1500/HCFA form to the defendant for an MRI bill on April 19, 2009. The CMS 1500/HCFA form was a global bill which included charges for the technical and professional components of the MRI, billed as CPT Code 72141. Plaintiff did not include a professional license number in Box 31 of the CMS 1500/HCFA form submitted to defendant. Defendant denied payment of the bill based on its position in its Explanation of Reimbursement (EOR) which stated that the “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.” Plaintiff filed a complaint in this Court for damages for no-fault benefits based on defendant’s failure to pay the submitted claim. Defendant filed an answer and affirmative defenses, including the affirmative defense of lack of notice because the CMS 1500 form was not properly completed pursuant to Florida PIP Statute 627.736. It is undisputed that at the time defendant denied payment there were sufficient funds to pay plaintiff’s claim.
While this case was ongoing, defendant moved for a stay of the proceedings because the issue of Box 31 was before the appellate court and this Court granted the stay. Despite the fact that defendant denied plaintiff’s claim and this case was stayed, defendant continued to pay claims submitted by the assignor’s other medical providers, resulting in the exhaustion of all benefits under the policy except for approximately $13.00.
At the time defendant denied plaintiff’s claim, there was no binding authority as to whether a professional medical license number was required in Box 31 of the CMS 1500/HFCA form. In fact, this was a hotly contested issue, with County Court opinions finding in favor of both the plaintiff’s and the defendant’s arguments. This Court had issued opinions in other cases that a doctor who deleted his license number failed to properly complete the CMS1500/HFCA form; and also ruled that it was not possible for an MRI provider to furnish a license number they did not possess.
Subsequently, the Fourth District Court of Appeals decided the case of USAA Casualty Insurance Company v. Pembroke Pines MRI Inc. (a/a/o Megan Cahill), 31 So.3d 234 (Fla. 4th DCA 2010) [35 Fla. L. Weekly D613b]. In that case, which is factually similar to the case at bar, the trial court found that Pembroke MRI was not required to supply a professional license number under section 627.736(5)(d), as it was not a professional and not required to retain a professional license number and entered summary judgment in favor of Pembroke MRI. The Fourth District Court of Appeals held that the trial court did not err in its interpretation of section 627.7369(5)(d) and did not err in granting summary judgment “because Pembroke MRI, by substantially completing the CMS 1500 form, provided USAA with notice of a covered loss.” Id. The Court found that because Pembroke MRI fulfilled section 627.736(5)(d)’s notice requirements it was entitled to recovery.
In light of this holding, defendant confessed judgment and tendered payment of $14.51 which represented the remaining benefits plus interest to plaintiff, which was less than the amount billed by the plaintiff because defendant had exhausted the benefits paying other claims even as this matter was stayed.
Defendant subsequently moved to amend the affirmative defenses to include the affirmative defense of exhaustion of benefits. Defendant further moved for summary judgment based on the affirmative defense of exhaustion of benefits. Plaintiff also moved for summary judgment arguing that defendant never had “reasonable proof’ that it was not responsible for the claim; that defendant attempted to avoid payment solely based on improper notice of a claim and therefore acted in bad faith in denial of the claim because at the time the claim was made there were sufficient funds to pay plaintiff’s claim in full.
It is well settled that “disposition of a case on appeal should be made in accord with the law in effect at the time of the appellate court’s decision rather than the law in effect at the time the judgment appealed was rendered.” Hendeles v. Sanford Auto Auction, 364 So.2d 467, 468 (Fla. 1978) (citations omitted). As such, the holding in Cahill must be retrospectively applied to this case. Therefore, it is undisputed that defendant did not have reasonable proof at the time it denied plaintiff’s claim and that defendant rested upon its legal position that was rejected by Cahill. Defendant does not deny this but now argues that it cannot be held liable for payments once PIP benefits have been exhausted in the absence of bad faith, relying on Simon v. Progressive Express Insurance Company, 904 So.2d 449 (Fla. 4th DCA 2005) [30 Fla. L. Weekly D1156b], and Progressive American Insurance Company v. Stand-Up MRI of Orlando, 990 So.2d 3 (Fla. 5th DCA 2008) [33 Fla. L. Weekly D1746a]. Defendant argues that there can be no bad faith because it relied on a legal position that was subsequently invalidated. However, bad faith is not the issue. Based on the retrospective application of Cahill, defendant having had no reasonable proof that it was not responsible for plaintiff’s claim when plaintiff had put defendant on timely notice, failed to timely pay PIP benefits as required under section 627.736(4)(b). This occurred long before it exhausted the benefits. Moreover, both Simon and Stand Up MRI are distinguishable from the instant matter. In Simon, it was found that Dr. Simon accepted a reduced payment without protest and as such the defendant had reasonable proof it was not responsible for the remainder. In Stand Up MRI, the defendant had an IME/Peer Review which found that the medical services in question were not medically necessary and that this was reasonable proof. In this case, defendant’s only reason for denying plaintiff’s claim was lack of notice. As such, defendant is liable for plaintiff’s claim.
Accordingly, it is hereby
ORDERED AND ADJUDGED that defendant’s motion for summary judgment is DENIED.
It is further ORDERED AND ADJUDGED that plaintiff’s motion for summary judgment is GRANTED. Judgment is hereby entered in favor of plaintiff in the amount of $914.21 together with interest at 8% per annum from April 23, 2009, less set-off for $14.51 which was paid on April 21, 2010.
The Court reserves jurisdiction to determine entitlement to reasonable attorney’s fees and costs.
