19 Fla. L. Weekly Supp. 145a
Online Reference: FLWSUPP 1902ORTIInsurance — Personal injury protection — Delay in payment — Request for information or documentation — Where medical provider made no response to insurer’s request for information and documentation, summary judgment is entered in favor of insurer — No merit to provider’s argument that summary judgment is inappropriate at this time because provider was precluded from asking claims adjuster in deposition whether insurer had regular practice of requesting additional information where there is no evidence or formal claim that defendant engaged in unfair trade practice or improperly utilized request mechanism
BEST MEDICAL HEALTHCARE SOLUTIONS, LLC., as assignee of Ana Ortiz, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 11-CC-003874. November 1, 2011. Matthew C. Lucas, Judge.
ORDER GRANTING DEFENDANT’S MOTIONFOR SUMMARY JUDGMENT
THIS CAUSE, having come before this Honorable Court on October 18, 2011, on Defendant’s Motion for Summary Judgment, and the Court having reviewed the file, having heard argument of counsel, and after being fully advised in the premises herein, the Court finds as follows:
I. Undisputed Facts
1. Defendant issued a personal automobile insurance policy to Isidoro Rotestan which provided Personal Injury Protection (hereinafter “PIP”) benefits, subject to the terms and conditions of the policy and as otherwise provided for by Florida Statutes, §627.736.
2. On June 12, 2010, while the aforementioned policy was in full force and effect, Ana Ortiz was purportedly involved in a motor vehicle accident while occupying Isidoro Rotestan’s vehicle.
3. As a result of the aforementioned motor vehicle accident, it was alleged that Ms. Ortiz sought treatment with the Plaintiff.
4. Best Medical Healthcare Solutions, LLC, pursuant to an assignment of benefits executed by Ms. Ortiz, submitted claims to Defendant seeking direct payment of PIP benefits for dates of service from June 17, 2010 through September 28, 2010. The Defendant received the initial set of those CMS-1500 forms on or about July 27, 2010.
5. The aforementioned dates of service were never paid by Defendant.
6. Instead, on August 3, 2010 (less than 30 days from receipt of the medical bills for the first date of service at issue in this litigation), Defendant requested additional documentation and information from Best Medical Healthcare Solutions, LLC, regarding the history, condition, treatment and costs of treatment purportedly provided to Ms. Ortiz pursuant to Florida Statutes, §627.736(6)(b).
7. It is undisputed that Best Medical Healthcare Solutions, LLC, never responded to this request.
8. On or about February 21, 2011, Best Medical Healthcare Solutions, LLC, as assignee of Ana Ortiz, filed suit against Defendant alleging that Defendant failed to pay PIP benefits in a timely manner in accordance with the policy and applicable Florida law.
9. On or about March 14, 2010, Defendant served its Answer and Affirmative Defenses to Plaintiff’s Complaint which raised, as an affirmative defense, the following:
Plaintiff has failed to comply with Florida Statute §627.736(6)(b) in that it failed to respond to STATE FARM’S request for further information, which was sent out within 30 days of the dates of service being submitted to STATE FARM and at issue in this case. That letter is dated August 3, 2010.
10. On or about October 18, 2011, this Court heard argument on Defendant’s Motion for Summary Judgment (filed with the Court on June 8, 2011).
II. Legal Analysis
11. Florida Statutes, §627.736(6)(b) provides, in pertinent part, as follows:
(6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.
(b) Every physician, hospital, clinic, or other medical institution providing, before or after bodily injury upon which a claim for personal injury protection insurance benefits is based, any products, services, or accommodations in relation to that or any other injury, or in relation to a condition claimed to be connected with that or any other injury, shall, if requested to do so by the insurer against whom the claim has been made, furnish forthwith a written report of the history, condition, treatment, dates, and costs of such treatment of the injured person and why the items identified by the insurer were reasonable in amount and medically necessary, together with a sworn statement that the treatment or services rendered were reasonable and necessary with respect to the bodily injury sustained and identifying which portion of the expenses for such treatment or services was incurred as a result of such bodily injury; and produce forthwith, and permit the inspection and copying of, his or her or its records regarding such history, condition, treatment, dates, and costs of treatment; provided that this shall not limit the introduction of evidence at trial. Such sworn statement shall read as follows: “Under penalty of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief.” No cause of action for violation of the physician-patient privilege or invasion of the right of privacy shall be permitted against any physician, hospital, clinic, or other medical institution complying with the provisions of this section. The person requesting such records and such sworn statement shall pay all reasonable costs connected therewith. If an insurer makes a written request for documentation or information under this paragraph within 30 days after having received notice of the amount of a covered loss under paragraph (4)(a), the amount or the partial amount which is the subject of the insurer’s inquiry shall become overdue if the insurer does not pay in accordance with paragraph (4)(b) or within 10 days after the insurer’s receipt of the requested documentation or information, whichever occurs later. For purposes of this paragraph, the term “receipt” includes, but is not limited to, inspection and copying pursuant to this paragraph. Any insurer that requests documentation or information pertaining to reasonableness of charges or medical necessity under this paragraph without a reasonable basis for such requests as a general business practice is engaging in an unfair trade practice under the insurance code. (emphasis added)
12. Plaintiff argues that summary judgment is inappropriate at this time since it was precluded from asking the claims adjuster, in deposition, the following questions:
a. In how may — in what percentage of the cases that you individually adjust as an SIU adjuster do you issue a 6(b) letter or request for additional information?
b. . . .is the letter that you sent in Ana Ortiz’s claim based on a form that you use whenever you send out a 6(b) letter?
13. The Defendant objected to these questions based upon its position that claim handling practices and procedures were irrelevant in a breach of contract case and thereby moved for a protective order from the Court prior to answering same. The Plaintiff never moved to compel such testimony.
14. The Court finds that there is no disputed material fact that the Defendant submitted a 6(b) request for additional records and documents to the Plaintiff.
15. The Court further finds that the Plaintiff never provided records, documents, or the required affidavit in response to the Defendant’s 6(b) request.
16. There has been no evidence presented, or even a formal claim made, that the Defendant engaged in unfair trade practice or that the Defendant had improperly utilized the 6(b) request mechanism. There has been an allegation, but there is no claim or affirmative defense or any kind of pleading that the allegation relates to. The Court, therefore, finds that the issue raised by the Plaintiff as to the discovery dispute relates to collateral issues and would be protected by attorney/work product, but in all events are irrelevant to the disposition of this case.
17. Based on the unambiguous terms of the Florida Statute §627.736, and in line with the analyses stated in various rulings of the Hillsborough County Circuit Court, it is hereby ORDERED AND ADJUDGED as follows:
18. Defendant’s Motion for Summary Judgment is hereby GRANTED. It is further,
19. ORDERED AND ADJUDGED that the Plaintiff, Best Medical Healthcare Solutions, LLC, as assignee of Ana Ortiz, shall take nothing by this suit as to Defendant, State Farm Mutual Automobile Insurance Company, and Defendant shall go hence without day. It is further,
20. ORDERED AND ADJUDGED that this Honorable Court hereby reserves jurisdiction to determine Defendant’s entitlement to recover its reasonable attorney’s fees and costs, and any other relief the court deems just and proper.
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