23 Fla. L. Weekly Supp. 176b
Online Reference: FLWSUPP 2302MONSInsurance — Personal injury protection — Coverage — Lawfully rendered services — Where, during time that services were rendered to insured, medical provider falsely identified licensed massage therapist as its owner in order to circumvent licensure requirements of Health Care Clinic Act, services were not lawfully rendered and neither insurer nor insured is liable for charges — Further, neither insurer nor insured is required to pay claim to provider that knowingly submitted false and misleading claims
TROPICAL HEALING POWER, LLC, as assignee of Heriberto Mons, Plaintiff, v. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 10-CC-033535, Division L. February 13, 2015. Honorable Kim Hernandez-Vance, Judge. Counsel: Stuart Yanofsky, Plantation, for Plaintiff. Kimberly Beckwith and Chad Guzzo, Martinez Denbo, LLC, Tampa, for Defendant.
FINAL SUMMARY JUDGMENTIN FAVOR OF DEFENDANT
THIS CAUSE, having come for consideration upon Defendant’s Motion for Final Summary Judgment, and the Court having heard the arguments of both parties and being fully advised in the premise finds as follows:
UNDISPUTED FACTS
1. This is an action for Personal Injury Protection (“PIP”) benefits and alleged damages related to purported breaches of contract by Progressive arising out of an October 24, 2009 motor vehicle accident involving Progressive’s claimant, Heriberto Mons.
2. According to the bills at-issue filed in this case, Heriberto Mons sought medical services/treatments in regards to the subject claim from the captioned Plaintiff from October 30, 2009 through December 14, 2009.
3. During this period, Plaintiff listed Florida licensed massage therapist Jorge Montoya Romero (“LMT Romero”) as its 100% owner.
4. However, at no time did LMT Romero have an ownership interest in Plaintiff clinic.
5. No counter-evidence to Progressive’s Motion for Final Summary Judgment was submitted by Plaintiff.
ISSUE AND ANALYSIS
6. The issue before this Court is whether the medical services provided by Plaintiff to Heriberto Mons were lawfully rendered and the corresponding bills lawfully submitted such that Plaintiff is entitled to reimbursement of PIP benefits in relation to same.
7. Pursuant to Florida Statute § 627.736 (2008), medical services are to be lawfully rendered and the corresponding bills are to be lawfully submitted. Allstate Ins. Co. v. Vizcay, 2011 WL 5870016 (M.D. Fla. Nov. 22, 2011).
8. As stated in Florida Statute § 627.736(5)(d) (2008):
No statement of medical services may include charges for medical services of a person or entity that performed such services without possessing the valid licenses required to perform such services. For purposes of paragraph (4)(b), an insurer shall not be considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph. . . .
9. Additionally, an insurer has the right to challenge a violation of Florida Statute 627.736(5) at any time. See Florida Statute § 627.736(4)(b) (2008). This includes potential licensure violations, which encompasses a determination of the ownership of a medical clinic, such as Plaintiff. See State Farm Fire & Cas. Co. v. Silver Star Health & Rehab, 739 F. 3d 579 (11th Cir. 2013) [24 Fla. L. Weekly Fed. C834a]; Allstate Ins. Co. v. Vizcay, 2011 WL 5870016.
10. Florida’s Health Care Clinic Act (“Act”), Florida Statutes §§ 400.990-400.995, controls the licensing of medical clinics such as Plaintiff. The Act “requires that all medical clinics operating in Florida be licensed by the State unless they fall within a statutory exemption. [citation omitted]. One of the exemptions is for clinics that are ‘wholly owned by one or more licensed health care practitioners.’ [citation omitted].” Silver Star Health & Rehab, 739 F. 3d at 582.
11. Accordingly, a medical clinic, such as Plaintiff, is required to possess valid licenses, including licenses under the Act, in order for medical services to be lawfully rendered and corresponding bills to be lawfully submitted under Florida’s No-Fault law. See Silver Star Health & Rehab, 739 F. 3d 579; Allstate Ins. Co. v. Vizcay, 2011 WL 5870016.
12. In the instant action, the subject medical services were provided by Plaintiff to Heriberto Mons from October 30, 2009 through December 14, 2009.
13. During this specific time period, Plaintiff falsely identified LMT Romero as its owner in order to circumvent the requirements of Florida’s No-Fault law and the Act. These actions by Plaintiff preclude the at-issue medical services from being lawfully rendered such that neither Progressive nor its claimant, Heriberto Mons, is liable to Plaintiff for the at-issue medical services and corresponding bills. See Fla. Stat. § 627.736(5)(b)1.b.
14. Additionally, Florida Statute § 627.736(5)(b)1.c. provides in part that neither an insurer nor an insured is required to pay a claim or charges “[t]o any person who knowingly submits a false or misleading statement relating to the claim or charges. . . .” Fla. Stat. § 627.736(5)(b)1.c. (2008).
15. “ “Knowingly” means that a person, with respect to information, has actual knowledge of the information; acts in deliberate ignorance of the truth or falsity of the information; or acts in reckless disregard of the information, and proof of specific intent to defraud is not required.” Fla. Stat. § 627.732 (2008).
16. Accordingly, a medical provider’s submission of “[a]ny knowingly misleading or false charge, by definition, is unreasonable, not medically necessary, and in excess of permitted amounts” Chiropractic One, Inc. v. State Farm Mut. Automobile Ins. Co., 92 So. 3d 871, 874 (Fla. 5th DCA 2012) [37 Fla. L. Weekly D1565a].
17. Actions by a medical provider, as outlined in the preceding paragraphs, entitle an insurer, such as Progressive, to dispositive relief in relation to the medical provider’s entire claim. Chiropractic One, 92 So. 3d at 874.
18. During the specific at-issue time period, Plaintiff knowingly submitted false and/or misleading claims to Progressive that sought reimbursement of PIP benefits for which it knew it was not entitled to under Florida’s No-Fault law.
19. These actions by Plaintiff in submitting materially false claims to Progressive for payment of PIP benefits demonstrates that Plaintiff had actual knowledge of the false or misleading nature of the claims; that Plaintiff acted in deliberate ignorance of the truth or falsity of the information; and/or that Plaintiff acted in reckless disregard of the false or misleading information upon which it knew Progressive would rely in processing the subject claim.
20. In accordance with Florida Statue § 627.736(5)(b)1.c. (2008), by knowingly submitting false or misleading claims to Progressive in relation to the subject PIP claim, Plaintiff has forfeited any right it may have had to be compensated by either Progressive or Heriberto Mons for the subject claim.
21. The aforementioned actions by Plaintiff materially prejudiced both Progressive and Heriberto Mons as Plaintiff knowingly sought an amount in excess of what it was entitled to for the services allegedly provided. Specifically, Plaintiff’s actions show an attempt to potentially deny Heriberto Mons additional PIP benefits that would have been available to him for additional treatment for the bodily injuries he sustained in the subject motor vehicle accident. Such actions would directly lead to Heriberto Mons incurring additional, unnecessary charges for medical treatment that could have been potentially covered under the PIP portion of the subject insurance policy. Further, Progressive would have been additionally prejudiced in that it would have been paying PIP benefits for claims that are not properly payable under Florida No-Fault law.RULING
22. At all times material to this lawsuit, Plaintiff could not comply with the Act’s licensing requirements as Jorge Montoya Romero was at no time the 100% owner of Plaintiff Tropical Healing Power, LLC. Accordingly, Plaintiff could not lawfully render medical services or lawfully submit the corresponding bills as required by Florida’s No-Fault law such that neither Progressive nor its claimant, Heriberto Mons, is liable to Plaintiff for the subject medical services/treatments. See Fla. Stat. §§ 627.736(5)(b)l.b. and (5)(b)1.c.
23. Additionally, Plaintiff’s lack of proper licensure, including licensure under the Act, violated Florida Statutes §§ 627.736(1)(a), (5)(a), 5(b)1. and 5(d); Florida Statute § 627.732(11); and Florida Statute § 400.9935(3).
24. Thus, Progressive’s Motion for Final Summary Judgment is GRANTED.
25. This Court reserves jurisdiction in relation to the potential award of attorneys’ fees and costs to Defendant.
