18 Fla. L. Weekly Supp. 579b
Online Reference: FLWSUPP 1807IEST
Insurance — Personal injury protection — Coverage — Withdrawal of benefits — Retroactive notice of withdrawal — Insurer is not precluded from suspending benefits retroactively to date of independent medical examination which revealed that treatment was not reasonable, related or necessary — Question of whether services were reasonable, related or necessary is for jury to decide — Error to enter summary judgment finding as matter of law that controlling date for suspension of benefits was date of IME suspension letter, not date of IME
UNITED AUTOMOBILE INSURANCE COMPANY, Appellant, v. HIALEAH MEDICAL ASSOCIATES, INC., a/a/o ILEANA ESTRADA, Appellee. Circuit Court, 11th Judicial Circuit (Appellate) in and for Miami-Dade County. Case No. 08-272 AP. L.C. Case No. 2006002957SP21. Hearing On: May 13, 2010. Opinion filed April 6, 2011. On Appeal from the County Court for Miami-Dade County, Ana M. Pando, Judge. Counsel: Ivy R. Ginsberg, for Appellant. Rima C. Bardawil, for Appellee.
(Before, BUTCHKO, DIAZ, TINKLER-MENDEZ, JJ.)
(TINKLER-MENDEZ, Judge.) This appeal seeks to reverse the lower court’s order granting summary judgment to Appellee, Hialeah Medical Associates, Inc. Specifically, Appellant United Auto Insurance Company (hereinafter “UAIC”), argues that the determination of the timeliness and effective date of the suspension of benefits letter based on the insurance company’s doctor’s independent medical examination (IME) is a factual issue for the jury to decide and not subject to a summary judgment by the court as a matter of law.
Statement of the Case and Facts
On October 4, 2004, the Insured was involved in an automobile accident and claimed personal injuries that required medical treatment. The Insured had an automobile insurance policy for PIP benefits with UAIC. The Insured received medical treatment from Hialeah Medical Associates, Inc., and submitted its bills to UAIC and further signed an Assignment of Benefits to Hialeah Medical Associates, Inc.
On November 5, 2004, the Insured was noticed to attend an independent medical examination under oath, and, thereafter, on November 10, 2004, attended the examination conducted by Dr. Peter Millheiser. The next day the insured received notice to attend a second examination and did so with Dr. Neil Fleischer on December 1, 2004.
Approximately a week later, on December 7, 2004, UAIC sent out a letter advising both the Insured and the provider that they were retroactively suspending benefits to November 10, 2004, this based on Dr. Millheiser’s findings. The Insured’s policy covered her for up to 10,000.00 in medical expenses with a $1,000.00 deductible. UAIC received a bill from the provider in the amount of $1,450.00 for dates of services rendered to the insured preceding the December 7, 2004 suspension of benefits letter. UAIC refused to pay any portion of this bill.
On May 26, 2006, Hialeah Medical Associates, Inc. filed a complaint for breach of contract of the PIP benefits. In its answer and affirmative defenses, UAIC, alleged that the medical bills were in excess of the usual customary charges for such services, and, further alleged that some of the treatment was not reasonable, related, or necessary. UAIC further submitted that the suspension of benefits letter was sent to the Insured and provider in a timely manner and was sent based on the two IME’s conducted on November 10 and December 1, respectively.
The case was set for trial. However, during a pre-trial conference held on October 29, 2007, the Court issued certain instructions in order to narrow and simplify the factual and legal issues, and further directed the parties to file all pre-trial motions in order to expedite the disposition of the case. Thereafter, the Court heard several motions in limine filed by both parties. At the conclusion of the motions’ hearing, Hialeah Medical Association, Inc. argued for summary judgment as to certain issues raised.
Specifically, Hialeah argued that the effective date for suspension of benefits was the date the IME suspension of benefits letter was actually sent to the Insured or provider, which was December 7, 2004, and the Court could make this finding as a matter of law. UAIC countered and argued that the effective date for suspension of benefits is retroactive in this case to November 10, 2004, the date the insured attended the medical examination with Dr. Millheiser. The Court ruled in favor of Hialeah Medical Associations, Inc. finding that, as a matter of law, the controlling date for suspension of benefits to the insured was the date the IME suspension of benefits letter was actually mailed. Summary Judgment was granted in favor of the provider, Hialeah Medical Association, Inc. and UAIC was ordered to pay the provider $916.80 for services rendered to the insured for the period prior to December 7, 2004.
This appeal followed. Here, UAIC seeks reversal of the trial court’s order granting summary judgment and finding that, as a matter of law, the effective date for suspension of benefits ran from the date the IME suspension of benefits letter was sent to the insured and the provider, and not from the date of the medical examination. UAIC argues that the suspension of benefits letter was sent in a reasonable time, and, further, that the question of whether the services provided were reasonable, related and necessary are questions for a jury to decide.
Argument
The standard of review for a lower court’s order granting summary judgment is de novo. Sierra v. Shevin, 767 So.2d 524 (Fla. 3d DCA 2000). The reviewing court must determine whether there is a genuine issue of fact and whether the trial court applied the correct rule of law. Volusia County v. Aberdeen at Ormand Beach, L.P., 760 So.2d 126 (Fla. 2000).
In examining Florida law on withdrawal of authorization for treatment, the decision in United v. Marucci Wellness Centers, LLC., a/a/o Haraman Sila, 16 Fla. L. Weekly Supp. 503a (Fla. 11th Circuit Appellate 2009), is instructive. The Marucci court looked at the language of Florida Statute § 627.736(7)(a)(2008) and the legislative intent of the statute. The Court concluded that, clearly, the intent of the statute was to allow the insurance company to refuse payment to the provider and insured for both past and future medical services where there was a finding that the treatment was not reasonable, related, or necessary.
Furthermore, Florida courts have held that the insurer may retroactively deny a PIP claim after it has become due if there is sufficient evidence and reasonable proof in the form of the IME supporting denial. United Auto. Ins. Co. v. Rodriguez, 808 So.2d 82, 87 (Fla. 2001) [26 Fla. L. Weekly S747a], See also, Partners in Health Chiropractic v. United Auto. Ins. Co., 21 So.3d 858 (Fla. 3d DCA 2009) [34 Fla. L. Weekly D2177a] (stating that an insurer may deny a claim after it is overdue provided it has reasonable proof that it is not responsible for payment).
In the case at bar, UAIC sent out notification suspending benefits retroactively to the November 10, 2004 IME which revealed that treatment was not reasonable, related, or necessary. While this notification letter was not sent until December 7, 2004, this does not, as a matter of law, preclude UAIC from suspending benefits retroactively to the date the IME was actually conducted. It is then for a jury to ultimately decide if the services rendered to the insured by Hialeah Medical Associates, Inc., were reasonable, related, or necessary.
Wherefore, the lower court order granting summary judgment to Appellee, Hialeah Medical Associates, Inc., is hereby reversed and this case is remanded for further proceedings consistent with this opinion. (BUTCHKO and DIAZ, JJ., concur.)
