19 Fla. L. Weekly Supp. 882a
Online Reference: FLWSUPP 1910EVANInsurance — Personal injury protection — Insurer may not challenge medical necessity and relatedness of services for which it has already paid benefits
GLENN V. QUINTANA, D.C., P.A. (A/A/O MELISSA N. EVANS), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 10-2856 SP 21(01). July 11, 2012. Honorable Jacqueline Schwartz, Judge. Counsel: Ryan Peterson, The Patiño Law Firm, Hialeah, for Plaintiff. David Bender, Matt Hellman, P.A., for Defendant.
PARTIAL ORDER ON PLAINTIFF’S MOTIONFOR FINAL SUMMARY JUDGMENT
In this case the Plaintiff, a PIP medical provider, had performed certain services on a patient, who was insured by the Defendant. State Farm indicated in its responses to the medical bills (called an “Explanation of Review”) that it was paying most of the medical bills, that it was reducing the price of some of the bills, and that other bills were not payable due to the National Correct Coding Initiative.
The Plaintiff moved for Summary Judgment, suggesting that State Farm should pay the additional, unpaid amounts. State Farm responded, in part, by filing the affidavit of Dr. Michael Mathesie. The affidavit alleged, inter alia, that some of the services already paid for by State Farm were not medically necessary, and not related to the accident. State Farm cites the cases United Automobile Insurance Co. v. Santa Fe Medical Center, a/a/o Telmo Lopez, 21 So.3d 60 (Fla. 3d DCA 2009) [34 Fla. L. Weekly D2051b], and Partners in Health Chiropractic, a/a/o Neocles Lebrun v. United Automobile Insurance Co., 21 So.3d 858 (Fla. 3rd DCA 2009) [34 Fla. L. Weekly D2177a]., as well as Fla. Stat. 627.736(4)(b), and argued that the Plaintiff should have to prove why services State Farm already paid for were medically necessary and related to the accident. Pertinent to the argument are the last two sentences in Fla. Stat. 627.736(4)(b), which is cited in both Partners in Health and Santa Fe, which suggest that:
“This paragraph does not preclude or limit the ability of the insurer to assert that the claim was unrelated, was not medically necessary, or was unreasonable or that the amount of the charge was in excess of that permitted under, or in violation of, subsection (5). Such assertion by the insurer may be made at anytime, including after payment of the claim or after the 30-day time period for payment set forth in this paragraph.”
State Farm reads (4)(b) to suggest that the insurance company can challenge the medical, necessity of services after payment is made for those specific services. The Plaintiff disagrees, and argues that (4)(b) should be read to mean that simply making payment on some services does not preclude the insurer from challenging unpaid services, but that the law does not say that the insurer can go back and essentially demand repayment for amounts already paid. To buttress its position, the Plaintiff cites the Bad Faith statutes — which prohibit the following actions by an insurer:
“Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed;” Fla. Stat. 626.9541(i)(3)(e)
and
“Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement;” Fla. Stat. 626.9541(i)(3)(f).
The Plaintiff argues that an insurance company must either affirm coverage, or deny coverage, for each medical bill. For State Farm to suggest, retroactively, that some of the bills it had already paid (and in effect, affirmed coverage for) are now not covered because they were unnecessary, would violate this provision of the bad faith statutes, and has been deemed an Unfair Trade Practice by our legislature.
The Court does not feel that when the legislature created 627.736(4)(b), that they intended for insurers to be able to retroactively deny previously paid bills, and so the Court finds in favor of the Plaintiff on this issue. Any of the services which were previously paid by State Farm are deemed medically necessary, and related to the accident.
The Court will hear the remaining arguments in this case on another date, to be re-set by the parties.
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