19 Fla. L. Weekly Supp. 413a
Online Reference: FLWSUPP 1905BOGRInsurance — Personal injury protection — Exhaustion of policy limits — Where there was no binding legal authority as to whether inclusion of professional license number on claim form was required at time insurer denied claim on that basis, insurer had reasonable proof to support denial of benefits and is not responsible for payment of claim after exhaustion of policy limits on other claims
PEMBROKE PINES MRI, INC. (A/A/O NOMI BOGROW), Plaintiff vs. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County, Civil Division. Case No. 09-009441 COCE 50. February 16, 2012. Honorable Peter B. Skolnik, Judge. Counsel: Charles Kane, for Plaintiff. Reuven T. Herssein, Law Offices of Herssein & Herssein, P.A., North Miami, for Defendant.
ORDER GRANTING USAA’S MOTION FORFINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on November 22, 2011, for hearing of the Defendant’s Motion for Final Summary Judgment, and the Court’s having reviewed the Motion, the entire Court file, and the relevant legal authorities; having heard argument of counsel; having made a thorough review of the matters filed on record; and having been sufficiently advised on the premises, the Court finds as follows:
The Issue before this Court is whether an insurer is required to pay a claim, after policy benefits have exhausted, when the insurer denied the claim based upon the status of law the time the bill was received and processed, when a subsequent binding legal opinion is rendered which invalidates the basis for the denial of said claim.
Findings of Fact: Plaintiff, a provider of MRI services, submitted a CMS 1500/HCFA form to the Defendant for two MRI services, billed on November 10, 2008. The CMS 1500/HCFA form was a global bill which included charges for the technical and professional components of the MRIs, billed as CPT Codes 72141 and 73720. It is undisputed that 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 upon its position in its Explanation of Reimbursement (EOR) which states that “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.” Subsequent to the receipt of Plaintiff’s bill, Defendant received additional bills from other medical providers which were paid, and which ultimately exhausted the PIP benefits available under the policy of insurance.
In light of the Fourth District Court of Appeals ruling in 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] (holding that a medical provider need only provide substantially accurate responses to the all relevant information and material elements on the CMS 1500/HCFA form), the Plaintiff claims that the Defendant never had “reasonable proof” that it was not responsible for the claim, and therefore, acted in bad faith in the denial of the claim.
Conclusions of Law: Florida law has well established that an insurer is not responsible for payment of any further benefits once PIP benefits have been exhausted under the policy, unless the insurer acts in bad faith in denying the claim or improperly manipulates the claim to avoid paying it. In this case, there is no dispute that the PIP benefits were exhausted by paying other legitimate claims. At that time, the Defendant acted in accordance with the law in denying the claim when the CMS 1500/HCFA form failed to contain a professional medical license number in Box 31.
Most recently, in Richard A. Sheldon, D.C., (a/a/o Travis Baliel) v. United Services Automobile Association, 2010 Fla. App. LEXIS 20245; 36 Fla. L. Weekly D23a (Fla. 1st DCA 2010), the First District Court of Appeals stated, “Florida courts have established that, once an insurer has paid out the policy limits to the insured (or to various providers as assignees), it is not liable to pay any further PIP benefits, even those that are in dispute.” Furthermore, pursuant to Progressive American Insurance Co. v. Stand-up MRI of Orlando, 990 So.2d 3 (Fla. 5th DCA 2008) [33 Fla. L. Weekly D1746a] Simon v. Progressive Express Insurance Co., 904 So.2d 449 (Fla. 4th DCA 2005) [30 Fla. L. Weekly D1156b], and Progressive Express Insurance Company, v. Millennium Diagnostic Imaging Center, Inc. a/a/o Alfonso Taboada, 14 Fla. L. Weekly Supp. 938a (Fla. 11th Jud. Cir. July 19, 2007), cert. denied, 2008 Fla. App. Lexis 10301 at *1, 33 Fla. L. Weekly D1742b (Fla. 3d DCA July 9, 2008), the Court finds no bad faith on the part of this Defendant which might require the insurance company to set aside disputed amounts. Bad faith does not exist when an insurer takes a legal position, relying upon the status of the law at that time, when there is no binding authority stating otherwise.
At the time the Defendant denied the Plaintiff’s claim, there was no binding legal authority as to whether a professional medical license number was required in Box 31 of the CMS 1500/HCFA form. At that time, Box 31 was a hotly contested issue, with County Court opinions finding favor of both the Plaintiff’s and the Defendant’s positions. However, the fact that there were non-binding County Court opinions opposite of the Defendant’s legal position on the Box 31 issue does not give rise to an assertion of bad faith in the handling of the claim. The Defendant had “reasonable proof” to deny the claim, based upon the fact that the CMS 1500/HCFA form was not properly completed, pursuant to Florida Statute §627.736(5)(d). Furthermore, the Defendant’s “reasonable proof” was supported by County Court opinions throughout the State of Florida. Although it is not the facts in this case, Plaintiff’s argument that Defendant did not have “reasonable proof” to deny the claim and acted in bad faith would hold more ground if the denial based upon Box 31 had occurred after the Cahill ruling was issued. However, as noted in Stand-up MRI, supra, “. . . The Defendant did nothing wrong here. They were under a contract to the insured for a limited amount of benefits. They paid that amount in total. They are not responsible for the insured’s over-use of the policy. The Defendant did not gain anything out of their actions. They fully performed their contract with the insured. It is to the insured that the assignees should look for any additional payments.”
Accordingly, Final Judgment in this case is hereby entered in favor of the Defendant, USAA CASUALTY INSURANCE COMPANY.
The Plaintiff shall take nothing in this action, and the Defendant shall go hence forth without day.
The Court reserves jurisdiction to determine and award reasonable attorney’s fees and costs.
* * *
