21 Fla. L. Weekly Supp. 195a
Online Reference: FLWSUPP 2102GRANInsurance — Personal injury protection — Coverage — Medical expenses — Inadequacy of record keeping is not lawful basis for nonpayment of PIP benefits — Insurer’s witness is precluded from testifying as to any inadequacy of medical records
NOB HILL CHIROPRACTIC a/k/a MICHAEL J. COHEN DC PA (a/a/o Kenrick Grant), vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-016548 COCE (54). June 26, 2013. Gary R. Cowart, Judge. Counsel: Susan Guller, Weston, and Emilio Stillo, Davie, for Plaintiff. David Bender, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTIONIN LIMINE REGARDING ANY CLAIM OFINADEQUATE MEDICAL RECORDS
THIS CAUSE came before the Court June 26, 2013, on Plaintiff’s Motion in Limine as it relates to any claim of Inadequate Medical Records, and the Court’s having reviewed the entire Court file; heard argument; reviewed relevant legal authorities; and been sufficiently advised in the premises, the Court finds as follows:
Background. This is a suit over unpaid PIP benefits. The Defendant utilized the services of Dr. Michael Mathesie DC who authored a 26 page report as to his review of various records.
Plaintiff is seeking to preclude the Defendant from eliciting Dr. Mathesie’s testimony as to his opinions as to insufficient or inadequate record keeping .
Conclusions of LawThe parameters of when PIP benefits are due and the legal basis which support the refusal to pay benefits are wholly controlled by Florida Statute § 627.736 (2003). Since the statute is in derogation of the common law, it must be strictly construed. Humana Health Plans v. Lawton, 675 So.2d 1832 (Fla. 5th DCA 1996) [21 Fla. L. Weekly D1299g]. The intent of the legislature must be determined primarily by the language of the statute, which when clearly and unambiguously articulated “must be given its plain and obvious meaning”. Ortega v. United Automobile Insurance Company, 847 So.2d 994 (Fla. 3rd DCA 2003) [28 Fla. L. Weekly D796a].
Florida Statute § 627.736 (1)(a) defines required benefits and states every policy shall pay 80% of all “reasonable expenses for medically necessary” medical services. Florida Statute § 627.736 (4) states that benefits are due and payable upon receipt of reasonable proof of such loss and the amount of expenses. Florida Statute § 627.736 (4)(b) states the insurance benefits are overdue if not paid within 30 days.
Florida Statute § 627.736 (5)(b) is significant as it outlines the reasons an insurer is not required to pay a claim or charges. Florida Statute § 627.736 (5)(d) merely states that “all statements and bills for medical services rendered by any physician” shall be in forms approved by the Centers for Medicare and Medicaid Services (CMS 1500 forms) utilizing CPT codes. In this case they were.
Totally absent from the PIP statute is any obligation to submit medical records in order to be paid1 or that the medical records maintained by the provider meet any standard for thoroughness as a precondition of payment by an insurer. Stated differently, no provision of the statute supports a claim that “deficient” medical records correlates to any evidence of a lack of medical necessity. Since the PIP statute does not specifically provide that inadequate record keeping is a lawful basis for non-payment, it may not form a lawful basis as to non-payment of the medical charges.
The PIP statute does not create any exception to the requirement to pay for medical charges premised upon any claimed inadequacies of the records. This precise issue has been addressed by at least three trial courts, all of which agreed that failure to maintain adequate medical records is not a defense to payment in a PIP case. South Florida Pain & Rehabilitation Inc. v. United Automobile Ins. Co. 16 Fla. L. Weekly Supp. 981b (Judge Trachman, Broward County 2009); Dr. Kim Reddick D.C. P.A. v. State Farm Mutual Automobile Ins. Co., 19 Fla. L. Weekly Supp. 487b (Volusia Cty Ct. 2012); Michael J. Delesparra DC PA (a/a/o Joseph Walkens) v. MGA Insurance Company Inc., 19 Fla. L. Weekly Supp. 854c (Judge Robert W. Lee, Broward Cty. Ct. 2012).
ORDERED and ADJUUDGED that Dr. Michael Mathesie is precluded from testifying at the time of trial as to any purported deficiency or inadequacy of the medical records, that the provider failed to comply with 64B2-17.0065 Minimal Record Keeping Standards, as well as all testimony that Plaintiff failed to maintain lawful records.
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1Unless requested pursuant to Florida Statute § 627.736 (6)(b) (2003).
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