20 Fla. L. Weekly Supp. 829a
Online Reference: FLWSUPP 2008IRVIInsurance — Personal injury protection — Coverage — Medical benefits — Second opinion sought after insurer terminated benefits following independent medical examination — Bill submitted under CPT Code for outpatient visit for the evaluation and management of a new patient was compensable under policy and Florida No-Fault Law notwithstanding insurer’s classification of claim as one for “second opinion independent Medical Examination” — Whether services were medically necessary and related to accident at issue and whether amount billed was reasonable are issues for jury to determine
COMPREHENSIVE CONSULTANTS GROUP, INC., a/a/o Joshua Irving, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 2009-SC-002920. May 7, 2013. Jerri L. Collins, Judge.
ORDER FOR PARTIAL SUMMARY JUDGMENT
This matter came before the court on March 20, 2013, on Plaintiff’s motion for partial summary judgment regarding the Defendant’s third affirmative defense. The court, having reviewed the motion, the court file, legal authorities and having heard argument of counsel, finds as follows:
1. This is a breach of contract action in which the Plaintiff seeks payment of Personal Injury Protection (“PIP”) benefits as assignee of the Defendant’s insured, Joshua Irving.
2. The Defendant denied payment of the Plaintiff’s bill based on the opinion of a chiropractic physician hired at the direction of Defendant to perform a compulsory medical examination of Joshua Irving. The examining physician opined that no further chiropractic treatment was medically necessary, and based thereon, the Defendant terminated Mr. Irving’s PIP benefits for chiropractic care.
3. After the Defendant terminated benefits for chiropractic treatment, Mr. Irving sought a second opinion from Dr. Gary Weiss. Dr. Weiss examined Mr. Irving and, contrary to the opinion of the Defendant’s examining physician, concluded that further chiropractic treatment would be beneficial to Mr. Irving, and would be medically necessary, reasonable and related to the subject automobile accident.
4. The Plaintiff, Dr. Weiss’s company, submitted a bill to the Defendant for the examination Dr. Weiss performed, utilizing CPT Code 99204 for an outpatient visit for the evaluation and management of a new patient. The Defendant denied payment on the basis of the previous termination of benefits for chiropractic care.
5. The Plaintiff submitted a statutory pre-suit demand letter, and when payment was not made in response thereto, commenced this action.
6. In response to the lawsuit, the Defendant raised several defenses. Defendant’s Third Affirmative Defense states:
Treatment/Expense Not Medically Reasonable, Necessary and Related. Defendant alleges that the medical expense claimed by the Plaintiff are not due under the policy of insurance or Florida Automobile Reparations Act in that these expenses are not medically reasonable, related, and necessary in connection with the subject accident. Specifically, under the subject policy of insurance, there is no coverage provision for a “second opinion independent Medical Examination” as performed by Plaintiff. Further, chiropractic care treatment had been terminated as a result of the Independent Medical Examination requested be performed by State Farm prior to Plaintiff’s examination of Mr. Irving. Plaintiff was aware of this result. (emphasis added).
7. Plaintiff takes issue with the language emphasized above in the Defendant’s third affirmative defense, and seeks partial summary judgment as to the defense that the services provided are not covered under the subject policy.
8. The subject policy, which is in the record as summary judgment evidence, states in pertinent part:
We will pay in accordance with the No-Fault Act for bodily injury to an insured, caused by an accident resulting from the ownership, maintenance or use of a motor vehicle:
1. Medical Expenses. 80% of the reasonable charges incurred for:
a. Medically necessary medical, surgical, X-ray, dental, ambulance, hospital, professional nursing and rehabilitative services, eyeglasses, hearing aids and prosthetic devices
d. The term “medically necessary” is added and defined as follows:
Medically necessary — means a medical service or supply that a prudent physician would provide for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptom in a manner that is:
1. In accordance with generally accepted standards of medical practice;
2. Clinically appropriate in terms of type, frequency, extent, site, and duration; and
3. Not primarily for the convenience of the patient, physician, or other health care provider.
9. Defendant’s semantics in describing the examination performed by Dr. Weiss as a “second opinion,” which it was, does not negate the fact that the services provided, evaluation and management of a patient under CPT Code 99204, are compensable services covered under the policy and the Florida No-Fault Law. Accordingly,
IT IS ADJUDGED that:
1. Plaintiff’s motion for partial summary judgment is GRANTED to the extent of Defendant’s affirmative defense that the services provided by Plaintiff are not compensable under the subject PIP policy.
2. The services at issue in this action are health care services that are compensable under the subject policy and the Florida No-Fault Law, and are routinely reimbursed under PIP insurance policies.
3. The court does not reach the issue of whether the services at issue were medically necessary, related to the subject accident, or reasonable in the amount billed, as those questions remain for a jury to determine.
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