23 Fla. L. Weekly Supp. 484a
Online Reference: FLWSUPP 2305SHOLInsurance — Personal injury protection — Coverage — Medical expenses — Insurer that has already made reduced payment on claim and is sued for balance of claim may raise relatedness and medical necessity of services as defense
PREMIER DIAGNOSTIC CENTER, LLC, a/a/o, Sean Holt, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 12-025325, Division 54. July 29, 2015. Stephen J. Zaccor, Judge. Counsel: Joseph R. Dawson, Law Offices of Joseph R. Dawson, P.A., Fort Lauderdale, for Plaintiff. Jose P. Font, Vernis & Bowling of Broward, P.A., Hollywood, for Defendant.
ORDER DENYING PLAINTIFF’S MOTION FORSUMMARY JUDGMENT AS TO THE MEDICALTREATMENT BEING RELATED AND NECESSARY
This cause came before the court on July 27, 2015 on Plaintiff’s Motion for Summary Judgment relative to whether the diagnostic testing was related and necessary. After reviewing the pleadings, the Explanation of Review, the assignment of benefits, the sworn statement of Sean Holt, the deposition of Dr. Brad Kern, and the affidavit of Dr. Randy Schulman, the evidence, the rest of the record, and after hearing argument of counsel for the parties, the court finds no there is a genuine issue of material fact and hereby denies Summary Judgment in favor of the Plaintiff.
ANALYSIS AND FINDINGS OF FACT
Premier Diagnostic Services, LLC (hereinafter the Plaintiff), sued State Farm Mutual Automobile Insurance Company (hereinafter the Defendant) for breach of a contract of personal injury protection benefits under the Florida’s No Fault law. It is undisputed the Defendant’s policy requires the Defendant to pay 80% of all reasonable expenses. In this case, the Plaintiff billed $1,950 for a cervical MRI. The Explanation of review establishes the Defendant received the bill and paid it based on 200% of the Participating Level of Medicare Part B ($860.30), and not 80% of the billed amount ($1,560.00). The amount tendered by the Defendant was not accepted as payment in full by the Plaintiff who, after serving a demand letter, sued the Defendant for breach of contract for the balance. The Plaintiff’s complaint was filed on November 26, 2012. In the Defendant’s Answer, filed on March 21, 2013, they allege the services in question were not medically necessary and not related to the motor vehicle accident. Not until July 21, 2015 did the Defendant furnish any evidence to support the lack of relatedness or necessity.
The Plaintiff moves for Summary Judgment on a pure question of law:
Whether the Defendant may be permitted to contest the medical necessity and causal relatedness to the subject motor vehicle accident of the medical diagnostic services rendered on behalf of Sean Holt, (“Claimant”) at the diagnostic testing facility of the Plaintiff on July 22, 2012, as reflected on the CMS 1500 form in the amount of $1,950.00?
Put more simply, Can the Defendant defend on relatedness and necessity after they have already made a payment on the claim and their initial challenge was only that the submitted charge was not reasonable? The Plaintiff contends the Defendant has waived relatedness and necessity as a defense because they paid, albeit less the than proper amount, the claim. The Defendant counters they can challenge relatedness and necessity at any time.
Section 627.736(4)(b)(6), Florida Statutes (2013) provides:
(b) Personal injury protection insurance benefits paid pursuant to this section are overdue if not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss and of the amount of same. However:
6. This paragraph does not preclude or limit the ability of the insurer to assert that the claim was unrelated, was not medically necessary, or was unreasonable or that the amount of the charge was in excess of that permitted under, or in violation of, subsection (5). Such assertion may be made at any time, including after payment of the claim or after the 30-day period for payment set forth in this paragraph.
“When the language of the statute is clear and unambiguous and conveys a clear and definite meaning, there is no occasion for resorting to the rules of statutory interpretation and construction; the statute must be given its plain and obvious meaning.” Rollins v. Pizzarelli, 761 So. 2d 294, 297 (Fla. 2000) [24 Fla. L. Weekly S69a], quoting Modder v. American Nat’l Life Ins. Co., 688 So.2d 330, 333 (Fla.1997) [22 Fla. L. Weekly S87a]. Furthermore, “significance and effect must be given to every word, phrase, sentence, and part of the statute if possible, and words in a statute should not be construed as mere surplusage.” Larimore v. State, 2 So. 3d 101, 106 (Fla. 2008) [33 Fla. L. Weekly S948a], as revised on denial of reh’g (Jan. 29, 2009) [34 Fla. L. Weekly S131a]. As applied here, “the plain and obvious meaning” of the statute is that the insurer can contest relatedness and necessity at any time, even after payment of the claim.
As the Plaintiff has moved for Summary Judgment strictly on a question of law, and that question of law has been resolved in favor of the Defendant, there is no need to analyze the Defendant’s evidence to see if it creates a genuine issue of material fact.
Accordingly, the Plaintiff’s Motion for Summary Judgment is hereby DENIED.
