5 Fla. L. Weekly Supp. 45a
Insurance — Personal injury protection — Error to find insured failed to comply with statute requiring that medical records be furnished to PIP insurer — Requirement applies to health care providers, not to insureds receiving medical attention — Insured fulfilled his duties under policy when he submitted proof of loss and authorized insurer to obtain medical reports and other pertinent records relating to incident giving rise to claim — Insurer may not require insured to provide it with all supporting medical records before receiving PIP benefits — Insurer must pay PIP benefits to claimant within thirty days of receiving notice of loss and amount of loss — Insurer has burden of authenticating claim within thirty-day statutory time period — Error to enter summary judgment in favor of insurer
CORDELL COULSON, Appellant, vs. FORTUNE INSURANCE COMPANY, Appellee. 11th Judicial Circuit in and for Dade County, Appellate Division. Case No. 96-228 AP. L.T. Case No. 94-6550 CC 25 (01). Opinion filed September 26, 1997. An appeal from the County Court of Dade County, Ann Mason Parker, Judge. Counsel: Fernando F. Freire, for Appellant. Joseph H. Lowe, for Appellee.
(Before MARGARITA ESQUIROZ, GERALD D. HUBBART and BARBARA S. LEVENSON, JJ.)
(PER CURIAM.) Appellant Cordell Coulson (“Coulson”), plaintiff below, appeals the final summary judgment granted in favor of Appellee Fortune Insurance Company (“Fortune Insurance”), defendant below.
On November 6th, 1993, Coulson was involved in an automobile accident. Subsequently, Coulson received medical treatment for injuries arising from the accident. At the time of the accident, Coulson carried an automobile insurance policy issued by Fortune Insurance. The insurance policy provided personal injury protection (“PIP”) benefits.
On February 8th, 1994, Fortune received an application signed by Coulson for PIP no-fault benefits. In the application, Coulson authorized the release of medical information to persons designated by Fortune.
Between February and April of 1994, Fortune received several bills for Coulson’s medical treatment. Fortune accepted the bills for payment, applied a percentage to exhaust the deductible, and paid the remainder to the health care provider(s).
In July of 1994, Fortune received a medical bill in the amount of $4,200.00 from Alpha Health Testing Systems (“Alpha Testing”) and also a separate medical bill in the amount of $420.00 from Dr. Adalberto P. Saavedra, an orthopedist.1 Shortly thereafter, Fortune requested that Alpha Testing and Dr. Saavedra provide MTC, Inc., a reviewing company retained by Fortune, with all medical records, office notes, tests, interpretations of the tests, fees, treatment plan, etc. Fortune requested this information to assist it in determining the reasonableness of the bills and necessity of the tests conducted on Coulson. Ten days later, MTC, Inc. sent a similar request to Alpha Testing and Dr. Saavedra on behalf of Fortune.
Although Dr. Saavedra responded to Fortune’s request for medical information, Alpha Testing failed to provide any information to Fortune or MTC, Inc. After a review of the information submitted by Dr. Saavedra, Fortune reduced the amount of Coulson’s bill from Dr. Saavedra and paid eighty percent of the reduced amount in benefits. Fortune paid nothing toward the $4,200.00 bill from Alpha Testing.
On September 19th, 1994, Coulson filed suit for PIP benefits on the unpaid Alpha Testing bill. A few weeks later, Fortune denied the claim for the Alpha Testing bill. Fortune based its denial on Alpha Testing’s failure to produce records, Dr. Saavedra’s alleged failure to provide complete and accurate records, and a review by an orthopedic doctor who opined that the studies conducted by Alpha Testing were unnecessary. The reviewing doctor allegedly based his opinion on Dr. Saavedra’s report.
On January 23rd, 1996, Fortune filed a motion for summary judgment. In its motion, Fortune asserted that the insurance policy, Florida statutes, and Florida case law require that all medical providers must submit medical records upon an insurer’s request. Fortune moved the court to enter summary judgment in its favor because Alpha Testing failed to provide the requested medical information, Dr. Saavedra allegedly failed to provide complete and accurate records, and because Fortune’s “expert” orthopedist allegedly concluded that the studies conducted by Alpha Testing were unnecessary.
On February 26th, 1996, the lower court granted Fortune’s motion for final summary judgment in favor of Fortune and against Coulson. The court found that “[t]he Plaintiff has failed to provide medical records as required by case law, statutes and his contract of insurance with Fortune Insurance Company.” See Final Summary Judgment, p. 5, 5. The court neglected to cite any case law that requires Coulson himself to provide medical records to Fortune. However, the court referred to §§ 627.736(6)(b) and 455.241(1) of the Florida Statutes, apparently as authority for the proposition that Coulson must provide medical records to Fortune and that he may not condition the furnishing of such records upon payment of a fee by Fortune for services rendered.2 See Final Summary Judgment, pp. 3-4, 4,5.
The lower court also quoted a provision in the insurance policy, which it interpreted as requiring Coulson to produce all supporting medical records.3 Id. at p. 3, 3. The court found that “[t]he failure to comply with Fortune Insurance Company’s or MTC’s request for accurate, true and complete records, including copies of nerve conduction studies was and is a failure to comply with condition precedents of the policy of insurance….” Final Summary Judgment, p. 5, 6. Based on this “failure to comply,” the court concluded that Fortune was precluded from having to pay additional PIP benefits to the insured or his health care providers. Id.
In his appellate brief, Coulson argues that he complied with the requirements of Florida statutes and case law, and with the conditions precedent of the insurance policy. He also contends that the burden of authenticating the claim rests upon the insurer, not the insured. We agree.
1. COULSON’S DUTY UNDER FLORIDA STATUTES
When interpreting a statute, courts must give the language of the statute its plain and ordinary meaning. Southeastern Fisheries Ass’n v. Dept. of Natural Resources, 453 So. 2d 1351, 1354 (Fla. 1984). We find that the lower court erred in its interpretation of §§ 627.736(6)(b) and 455.241(1) of the Florida statutes.
A. SECTION 627.736(6)(b)
The plain language of § 627.736(6)(b), Fla. Stat. (Supp. 1996) indicates that the requirement to furnish medical records to PIP insurers applies to health care providers, not to the insureds receiving medical attention. Section 627.736(6)(b) states that “[e]very physician, hospital, clinic, or other medical institution,” must furnish medical information, if requested, to an insurer (against whom the injured party has made a PIP benefits claim). The language of § 627.736(6)(b) places no duty on the insured to furnish medical records when filing a PIP benefits claim. As the Third District Court of Appeal explained in dicta, “[i]t is a common-sense proposition that patients, as a rule, do not have in their possession or control their own medical records.” Fortune Insurance Company v. Pacheco, 22 Fla. L. Weekly D1076, 1077 (Fla. 3d DCA April 30, 1997). Because § 627.736(6)(b) of the Florida statutes places the duty on Alpha Testing, not Coulson, to provide the requested medical records to Fortune, the lower court erred in finding that Coulson failed to comply with the Florida statute. In essence, the lower court erroneously held Coulson responsible for the conduct of third parties, Alpha Testing and Dr. Saavedra.
B. SECTION 455.241(1)
Section 455.241(1), Fla. Stat. (Supp. 1996) provides that “[a]ny health care practitioner” must, upon request, furnish medical records and reports to the person who received the treatment or to that person’s legal representative. Again, the plain language of the statute requires the medical provider, not the insured, to provide the medical information. Hence, § 455.241(1) places no duty on Coulson and the court erred in finding him responsible for the conduct of Alpha Testing and Dr. Saavedra.
II. COULSON’S DUTY UNDER THE
INSURANCE POLICY
The insurance policy clearly enumerates Coulson’s duties after an accident or loss. See Policy, p. 5, 1. In the subsection entitled “Duties After An Accident or Loss,” the policy requires the insured to promptly notify the insurer of how, when, and where the accident or loss occurred. Id., 1A. Furthermore, the person seeking coverage must, 1) cooperate with the insurer, 2) promptly send copies of any notices or legal papers received in connection with the accident, 3) submit to physical examinations and/or an examination under oath if so required by the insurer, 4) authorize the insurer to obtain medical reports and other pertinent records, 5) submit a proof of loss, and 6) report the accident to the local police. Id., 1B.
Following the accident, Coulson notified Fortune of the incident. He submitted a proof of loss and authorized Fortune to obtain medical reports and other pertinent records relating to the incident. Under the “Duties” provision, Coulson fulfilled his obligation when he authorized Fortune to obtain all pertinent records from the health care providers. The policy does not require Coulson to actually gather the medical records from the treating physicians and then provide them to Fortune. The lower court erred when it, in essence, imposed on Coulson a duty which is not prescribed by the insurance policy.
The insurance policy also states that the insured may not bring legal action against Fortune unless the insured complies with the terms of the policy and until thirty days after the required notice of accident and reasonable proof of claim. See Policy, p. 6, 5C (emphasis added). The lower court emphasized this provision in the insurance policy, which defines reasonable proof of claim as including “all supporting medical records.” Because Fortune did not receive all supporting medical records from Alpha Testing (nor adequate records from Dr. Saavedra), the court found that Coulson failed to comply with a condition precedent. According to the court, this failure precluded Coulson from receiving additional PIP benefits from Fortune.
Florida case law directly refutes the lower court’s conclusions. Recently, on analogous facts, the Third District Court of Appeal decided Fortune Insurance Company v. Pacheco, 22 Fla. L. Weekly D1076 (Fla. 3d DCA April 30, 1997). In Pacheco, the plaintiff was injured in an automobile accident and at the time of the accident, he carried an insurance policy issued by Fortune. Id. at 1077. As in the case sub judice, the plaintiff notified Fortune of the accident and submitted a PIP form and a copy of the medical bills to Fortune. Id. The plaintiff’s policy in Pacheco contained a provision identical to the provision quoted by the lower court in this case, requiring “reasonable proof of claim,” which includes “all supporting medical records.” Id. As in the case before this Court, Fortune referred the medical records to a reviewing company which subsequently sent a letter to a health care provider requesting test results, x-rays, office notes, etc. Id. In Pacheco, as in this case, Fortune did not pay the claim during the thirty-day time period established by § 627.736(4)(b) of the Florida statutes. Id. Fortune argued that the terms of the policy required the plaintiff to submit “all supporting medical records” with his claim for benefits before the thirty-day time period for payment begins to run. Id. The trial court in Pacheco rejected Fortune’s argument that the policy required the injured party to submit all supporting medical records before Fortune must pay PIP benefits pursuant to § 627.736(4)(b). Id.
Section 627.736(4)(b), Fla. Stat. (Supp. 1996) provides that the insurer must pay PIP benefits within thirty days after the insurer receives written notice of loss and the amount of the loss. “However, any payment shall not be deemed overdue when the insurer has reasonable proof to establish that the insurer is not responsible for the payment….” § 627.736(4)(b), Fla. Stat. (Supp. 1996) (emphasis added). The appellate court recognized that Fortune chose to define “reasonable proof” in its policy as including all supporting medical records. Pacheco, 22 Fla. L. Weekly D1077. The court rejected such a definition because “Fortune sought to determine when the thirty-day period to pay the claim would begin to run, and thus circumvent long-established case law that once an insurer receives notice of a loss and medical expenses, it must pay the claim within thirty days….” Id. The intent of § 627.736(4)(b) is to guarantee swift payment of PIP benefits. Crooks v. State Farm Mutual Auto. Ins. Co., 659 So. 2d 1266, 1268 (Fla. 3d DCA 1995). A provision such as the one in Fortune’s policy, which requires claimants to furnish all medical records before the thirty-day payment period begins to run, would defeat the purpose of § 627.736(4)(b). Pacheco, 22 Fla. L. Weekly D1077. As the court stated in Pacheco,
[T]he insurer cannot require the claimant to furnish those records before the thirty-day period begins to run. The insured fulfills his obligation to furnish medical records upon signing a waiver of confidentiality that allows the insurer to procure the records directly from the provider, who has the records, and who awaits payment.
Id. (emphasis in original).
Based on Pacheco, Fortune may not require Coulson to provide it with all supporting medical records before he may receive PIP benefits. Hence, the lower court erred in finding that Coulson failed to comply with a condition precedent by not furnishing Fortune with the records it requested from Alpha Testing.
III. FORTUNE’S DUTY
As stated previously, an insurer must pay PIP benefits to a claimant within thirty days of receiving notice of the loss and amount of loss. § 627.736(4)(b), Fla. Stat. (Supp. 1996). Within the thirty-day statutory time period, “the burden is clearly upon the insurer to authenticate the claim.…” Pacheco, 22 Fla. L. Weekly D1077 (emphasis added by court), quoting Dunmore v. Interstate Fire Ins. Co., 301 So. 2d 502 (Fla. 1st DCA 1974). In Martinez v. Fortune Ins. Co., 684 So. 2d 201, 203 (Fla. 4th DCA 1996), the Fourth District Court of Appeal gave effect to the decision in Dunmore, agreeing that the insurer carries the burden of authenticating the claim within thirty days of receiving notice of the claim. Interestingly, the Martinez case also involved Fortune’s failure to pay a claim because it had not received a requested report from a doctor. Id.
Clearly, the courts place the burden on the insurer, not the claimant, to investigate and obtain the information it needs to authenticate the claim. As demonstrated in Pacheco and Martinez, Fortune may not place the burden on the claimant to furnish all the information it requests from the claimant’s health care providers. Coulson satisfied the requirements to bring a claim for PIP insurance benefits when he notified Fortune of the loss and authorized Fortune to obtain medical information from his health care providers. The burden then shifted to Fortune to pay the claim or obtain reasonable proof that it was not responsible for the payment. Fortune failed to satisfy its burden.
Accordingly, we reverse the final summary judgment and remand the cause for further proceedings.
REVERSED and REMANDED.
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1Dr. Saavedra prescribed nerve conduction studies which Alpha Testing subsequently conducted.
2(1) In relevant part, § 627.736(6)(b), Fla. Stat. (Supp. 1996) provides that:
Every physician, hospital, clinic, or other medical institution providing, before or after bodily injury upon which a claim for personal injury protection insurance benefits is based, any products, services, or accommodations in relation to that or any other injury, or in relation to a condition claimed to be connected with that or any other injury, shall, if requested to do so by the insurer against whom the claim has been made, furnish forthwith a written report of the history, condition, treatment, dates, and costs of such treatment of the injured person, together with a sworn statement that the treatment or services rendered were reasonable and necessary with respect to the bodily injury sustained and identifying which portion of the expenses for such treatment or services was incurred as a result of such bodily injury, and produce forthwith, and permit the inspection and copying of, his or its records regarding such history, condition, treatment, dates, and costs of treatment.
(emphasis added by court in its order) See Final Summary Judgment, pp. 3-4, 4.
(2) In relevant part, § 455.241(1), Fla. Stat. (Supp. 1996) provides that:
Any health care practitioner licensed by the department or a board within the department who makes a physical or mental examination of, or administers treatment or dispenses legend drugs to, any person shall, upon request of such person or the person’s legal representative, furnish, in a timely manner, without delays for legal review, copies of all reports and records relating to such examination or treatment, including x rays and insurance information. … The furnishing of such report or copies shall not be conditioned upon payment of a fee for services rendered.
(emphasis added by court in its order) See Final Summary Judgment, p. 4, 5.
3The court referred to a provision in the insurance policy which states that:
No action shall lie against the Company unless there shall have been full compliance with all terms of this insurance, nor until 30 days after the required notice of accident and reasonable proof of claim has been filed with the Company. Reasonable proof of claim shall include but not be limited to: … (c) all medical expenses incurred as a result of the accident and all supporting medical records.
(emphasis added by court in its order) See Final Summary Judgment, p. 3, 3.
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