19 Fla. L. Weekly Supp. 22b
Online Reference: FLWSUPP 1901GALEInsurance — Personal injury protection — Coverage — Medical expenses — 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 medical provider’s 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 — Trial court erred in not entering summary judgment in favor of insurer on exhaustion of benefits defense
USAA CASUALTY INSURANCE COMPANY, Appellant. v. OAKLAND PARK MRI, INC a/a/o Antonia Gale, Appellee. Circuit Court, 17th Judicial Circuit (Appellate) in and for Broward County. Case No. CACE10-14286 (05). August 31, 2011. Counsel: Douglas Stein, Seipp & Flick, Miami, for Appellant. Harley N. Kane, Kane & Kane, Boca Raton, for Appellee.
[Lower court opinion at 17 Fla. L. Weekly Supp. 477a.]
OPINION
(EADE, Judge.) THIS CAUSE comes before the Court, sitting in its appellate capacity, upon the timely appeal by Appellant, USAA Casualty Insurance Company (herein “USAA”), of the Amended Final Judgment for Plaintiff entered on February 22, 2010. Having reviewed the brief, the record on appeal, and the motions filed in this case, the Court dispenses with oral argument and finds and decides in the absence of the answer brief as follows:
Background:
While insured under a personal injury protection (PIP) policy from USAA. Antonia Gale, was involved in an automobile accident on September 14, 2006. On November 2, 2006, Ms. Gale had an MRI at Oakland Park MRI, Inc. and assigned her rights to her PIP benefits to them. In turn, Oakland Park MRI submitted its bill for the MRI on November 20, 2006. Thereafter, USAA denied the claim alleging the medical provider did not submit proper notice of the claim because Oakland Park MRI presented a CMS 1500/HCFA form to USAA which did not include a professional license number in “Box 31” of the form.
Meanwhile, USAA continued to make payments on claims to Ms. Gale’s other medical provider after receipt of Oakland Park MRI’s bill. A payment to another medical provider in January 2007 exhausted all remaining PIP benefits available under the policy and the bill from Oakland Park MRI remained outstanding.
On August 7, 2007, Oakland Park MRI filed suit against USAA for damages alleging USAA’s failure to pay the medical bill within 30 days as required section 627.736(4)(b), Florida Statutes. USAA answered the complaint and alleged two affirmative defenses: (1) Oakland Park MRI failed to provide notice of the covered loss due to the missing professional license number: and (2) that Oakland Park MRI’s action is barred because the policy benefits were exhausted.
The parties filed cross-motions for summary judgment. The trial court rejected USAA’s motion for summary judgment based upon exhaustion of benefits, and instead, finding that the Oakland Park MRI was not required to have a professional license, entered partial summary judgment in favor of Oakland Park MRI on USAA’s “Box 31” affirmative defense. Ultimately, an amended final judgment on the parties’ cross motions for summary judgment was entered in favor of Oakland Park MRI. USAA’s timely appeal followed.
This Court will review the trial court’s order granting summary judgment de novo. Business Specialists, Inc. v. Land & Sea Petroleum, Inc., 25 So. 3d 693, 695 (Fla. 4th DCA 2010) [35 Fla. L. Weekly D199a].
At the time USAA denied Oakland Park MRI’s claim, there was no binding authority as to whether a professional license number was required in Box 31 of the CMS 1500/HFCA form. In fact, this was a hotly contested issue, with non-binding county court opinions finding in favor of both the plaintiff’s and the defendant’s arguments. In early 2010, but well after this matter was determined, the “Box 31” issue was settled by the Fourth District Court of Appeals in USAA Casualty Insurance Company v. Pembroke Pines MRI Inc. (a/a/o Meghan Cahill), 31 So. 3d 234 (Fla. 4th DCA 2010) [35 Fla. L. Weekly D613b]. In that case, 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 Cahill Court 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 Fourth DCA concluded that because Pembroke MRI fulfilled section 627.736(5)(d)’s notice requirements it was entitled to recovery.
On the record here, the denial of the Oakland Park MRI’s claim and the exhaustion of PIP benefits came well in advance of the Fourth DCA’s opinion in Cahill. Thus, when Oakland Park MRI’s claim was denied, it is undisputed that USAA had “reasonable proof” to deny the claim, based on the fact that the CMS 1500/HCFA forms were not properly completed, pursuant to Florida Statute section in 627.736(5)(d), Florida Statutes. Indeed, USAA’s “reasonable proof” was also supported by the county court opinions and orders being entered throughout the State of Florida. Because USAA had reasonable proof to support the denial of Oakland Park MRI’s claim, we now turn to the exhaustion of benefits.
In Richard A. Sheldon, D.C., (a/a/o Travis Baliel) v. United Services Automobile Association, 55 So. 3d 593 (Fla. 1st DCA 2010) [36 Fla. L. Weekly D23a], the appellate court 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. See also Simon v. Progressive Express Insurance Co., 904 So. 2d 449 (Fla. 4th DCA 2005) [30 Fla. L. Weekly D1156b].
Here, the undisputed evidence reveals that the PIP benefits were exhausted before Oakland Park MRI’s law suit was filed. Because USAA met its obligation under the contract to pay the policy amount, USAA’s motion for summary judgment should have been entered in favor of USAA on their exhaustion of benefits defense. See Progressive American Insurance Co. v. Stand-Up MRI of Orlando, 990 So. 2d 3 (Fla. 5th DCA 2008) [33 Fla. L. Weekly D1746a]. It is therefore,
ORDERED AND ADJUDGED that the trial court’s amended final judgment in favor of the Oakland Park MRI is hereby REVERSED and REMANDED for entry of a final summary judgment in favor of USAA Casualty Insurance Company consistent with this Opinion:
Appellant’s request for appellate attorney’s fees based upon the underlying proposal for settlement pursuant to Florida Rule of Civil Procedure 1.442 and section 768.79. Florida Statutes, is hereby conditionally granted and REMANDED to the trial court for consideration upon the trial court’s determination that USAA Casualty Insurance Company’s proposal complies with the requirements of the law, was timely served, and was made in good faith.
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