24 Fla. L. Weekly Supp. 308b
Online Reference: FLWSUPP 2404WROBInsurance — Personal injury protection — Coverage — Medical expenses — Timeliness of claim — Where medical provider was apprised at time of service that there was PIP coverage for claimant who was injured as passenger in insured’s vehicle and given means to ascertain insurance information from claimant’s personal injury attorney, provider elected instead to send CMS claim form to claimant’s attorney, attorney provided insurance information four months later, and provider submitted claim to insurer within 35 days of receipt of information, provider is not entitled to reimbursement for untimely submitted claim in absence of any evidence that either claimant or attorney provided erroneous information to provider
PRECISION DIAGNOSTIC OF LAKE WORTH, LLC. (a/a/o David Wroblewski), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 2014-4131 CONO 70. June 20, 2016. John Fry, Judge. Counsel: Victoria Hammonds, Florida P.I.P. Law Firm, P.A., Boca Raton, for Plaintiff. Ryan B. Weiss, Cole, Scott & Kissane, P.A., Miami, for Defendant.
[Editor’s note: Action was voluntarily dismissed with prejudice on August 16, 2016.]
ORDER GRANTING DEFENDANT’S MOTION FORFINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court for hearing on May 26, 2016 on Defendant’s Motion for Final Summary Judgment. The Court, having reviewed the motion, the Court file, legal authorities, and having heard argument of counsel, finds as follows:
STATEMENT OF FACTS
The facts relevant to the Defendant’s Motion for Summary Judgment are not in dispute and are supported by the record before this Court.
1. On or about April 11, 2014, Plaintiff, Precision Diagnostic of Lake Worth, LLC (hereinafter “Precision”) filed an action for damages against the Defendant, State Farm Mutual Automobile Insurance Company’s (hereinafter “State Farm”) seeking to recover Personal Injury Protection (“PIP”) benefits for services rendered unto David Wroblewski.
2. On or about January 18, 2013, David Wroblewski (hereinafter “Claimant”) was a passenger in an automobile owned and operated by State Farm named insured, Dale Kelley, which was involved in a motor vehicle accident, allegedly resulting in personal injuries to the claimant.
3. Personal Injury Protection coverage was extended to the claimant pursuant to the terms and conditions of the policy of insurance under issued to Dale Kelley, under which the subject claim was made and which by operation of law incorporates the version of the Florida Motor Vehicle No-Fault Law (§§627.730-627.7405, Florida Statutes 2013).
4. Among those provisions incorporated within the subject policy of insurance were §§627.736(5)(c)(1), which state in relevant part as follows:
(5) Charges for treatment of injured persons.
(c) 1. With respect to any treatment or service. . . the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 35 days before the postmark date. . . .
If, however, the insured fails to furnish the provider with the correct name and address of the insured’s personal injury protection insurer, the provider has 35 days from the date the provider obtains the correct information to furnish the insurer with a statement of the charges. The insurer is not required to pay for such charges unless the provider includes with the statement documentary evidence that was provided by the insured during the 35-day period demonstrating that the provider reasonably relied on erroneous information from the insured and either:
a. A denial letter from the incorrect insurer; or
b. Proof of mailing, which may include an affidavit under penalty of perjury, reflecting timely mailing to the incorrect address or insurer.
5. On February 21, 2013, the claimant presented at Precision for Magnetic Resonance Imaging (“MRI”) studies, at which time the claimant informed Precision that he was involved in a motor vehicle accident and was covered under a policy of insurance, but was unsure as to the information surrounding the policy itself, instructing Precision to contact his attorney to obtain the insurance information. The claimant provided Precision with his attorney’s contact information and executed a Letter of Protection in exchange for the services rendered.
6. On February 25, 2013, four (4) days after the date on which the service(s) at issue were rendered, Precision mailed a CMS-1500 claim form directly to the claimant’s personal injury attorney. Precision neither mailed nor electronically submitted a claim form for the service(s) at issue to any other person or entity at that time. Furthermore, Precision failed to file or otherwise submit a Notice of Initiation of Treatment, which under §627.736(5)(c), Florida Statutes, would have extended the thirty-five (35) day submission period to seventy-five (75) days.
7. Four (4) months later, on June 26, 2013, the claimant’s personal injury counsel informed Precision that the claimant was entitled to PIP coverage under the policy of insurance issued to Dale Kelley by State Farm.
8. Two (2) days following counsel’s advisement, on June 28, 2013, (One Hundred and Twenty-Eight days after the subject service was rendered) Precision mailed, for the first time, a CMS-1500 claim form to the Defendant, along with a letter indicting that Precision had just recently been informed that the claimant was covered under the subject policy of insurance.
9. Despite having been told of the existence of PIP coverage and being given the means to obtain the correct insurance information over four (4) months prior, Plaintiff failed to demonstrate that it had made any effort to obtain the proper policy information from either the claimant or claimant’s personal injury counsel.
10. The June 28, 2013 CMS-1500 claim form and letter from Precision was received by State Farm on July 2, 2013 (One Hundred and Thirty-One days after the subject service was rendered) and was ultimately denied because the bills were deemed untimely submitted pursuant to §627.736(5)(c)(1), Florida Statutes.
11. Precision was advised of State Farm’s claims decision via Explanation of Review and in response to its statutorily required Demand Letter, yet Precision still filed suit seeking to recover the PIP benefits claimed due and owing.
12. During the pendency and in response to Precision’s Complaint, Defendant raised its affirmative defense of untimely submission and later moved for summary judgment predicated upon Precision’s failure to comply with §627.736(5)(c)(1), Florida Statutes and submit its bills within the proscribed time period, despite Precisions attempt to employ the exception set forth within §627.736(5)(c)(2), Florida Statutes.LEGAL CONCLUSIONS
13. Florida Statue §627.736(5)(c)(1), Florida Statutes, states in pertinent part as follows:
(c) With respect to any treatment or service, other than medical services billed by a hospital or other provider for emergency services and care as defined in s. 395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 35 days before the postmark date or electronic transmission date of the statement, except for past due amounts previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement. The injured party is not liable for, and the provider may not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable.
1. If the insured fails to furnish the provider with the correct name and address of the insured’s personal injury protection insurer, the provider has 35 days from the date the provider obtains the correct information to furnish the insurer with a statement of the charges. The insurer is not required to pay for such charges unless the provider includes with the statement documentary evidence that was provided by the insured during the 35-day period demonstrating that the provider reasonably relied on erroneous information from the insured and either:
a. A denial letter from the incorrect insurer; or
b. Proof of mailing, which may include an affidavit under penalty of perjury, reflecting timely mailing to the incorrect address or insurer. (Emphasis Added)
14. It is undisputed that the MRI services at issue were rendered by Precision on February 21, 2013 and that Precision, despite having been advised of the existence of PIP coverage and having been given the means to obtain the name of the insurer; name of the insured; policy number and claim number, elected to submit its CMS-1500 claim form to the claimant’s personal injury counsel on February 24, 2013.
15. There is no record evidence to support, and Plaintiff failed to establish that, after the February 21, 2013 date of service, but prior to expiration of the 35-day submission window, Precision contacted the claimant’s personal injury counsel or otherwise sought to obtain the name of the insurer; name of the insured; policy number or claim number under which the subject bill could be properly and timely submitted in accordance with §627.736(5)(c), Florida Statutes.
16. In fact, based upon the record evidence submitted to this Court, it is apparent that Precision relied upon its Letter of Protection with the claimant’s personal injury counsel for payment and that it was not until four (4) months later, on June 26, 2013 when counsel for the claimant advised Precision of the existence of coverage under a State Farm policy of insurance that Precision took any remedial action.
17. Precision did ultimately submit its CMS-1500 claim form to State Farm, within thirty-five (35) days of learning the name of the insurer; name of the insured; policy number or claim number under which the subject bill could be submitted; however, there is no record evidence to support, and Plaintiff failed to establish, that it was provided erroneous information by either the claimant or claimant’s personal injury counsel.
18. As such, Precision could not refute State Farm’s assertion that Precision had failed to satisfy the statutory requirements for timely submission of bills outside of the proscribed thirty-five (35) day period.
19. This Court finds that Desaussure III v. Direct General Insurance Company, 18 Fla. L. Weekly Supp. 335a (Fla. 7th Cir. Ct. February 11, 2011) is distinguishable from the case at bar, as the provider in Desaussure III was expressly informed by the insured that he did not have insurance coverage. Further, the Court’s discussion of the Statute’s lack of imposition of a duty to investigate coverage spoke directly to whether coverage existed for the patient.
20. This Court finds that §627.736(5)(c), Florida Statutes proscribes the mechanism and time limits within which a provider must submit its claim for PIP benefits; providing thirty-five (35) days from the date of the service being rendered within which to properly submit its claim to the insurance carrier; extending this time period to seventy-five (75) days upon the timely filing of a Notice of Intent to Treat within twenty-one (21) days of the service being rendered. The Legislature even contemplated situations where the insured or claimant provides erroneous insurance information to the provider and provides relief under certain circumstances. In the case presently before this Court, those circumstances are not present.
21. The existence of coverage was never in question, and Precision was provided accurate contact information and means to obtain the details of the claimant’s insurance coverage so that it could properly and timely submit its claim to the appropriate entity for payment, yet Precision elected not to do so. There was no reasonable reliance upon erroneous information, there was a complete lack of due diligence on the part of Precision and that will not satisfy the exception of §627.736(5)(c), Florida Statutes.
Therefore it is Ordered and Adjudged that Defendant’s Motion for Summary Judgment is hereby GRANTED. Final Judgment is hereby entered against the Plaintiff, Precision Diagnostic of Lake Worth, LLC and in favor of the Defendant, State Farm Mutual Automobile Insurance Company. This Court retains jurisdiction to address the issue of attorney’s fees and costs.
