6 Fla. L. Weekly Supp. 721b
Insurance — Personal injury protection — Insurance company is required to obtain a report of a physician who conducted an independent medical examination of insured prior to reducing or denying a medical bill — Report of physician based only upon a records review does not meet the actual examination requirement of section 627.736(7)(a) — Insurer breached policy by denying payment of bills based on peer review and reducing bills without IME — Interest accrues on overdue payments from date bill is received through date payment is made
MICHELLE FIGUEROA, Plaintiff, v. GOVERNMENT EMPLOYEES INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 98-76272-SC, Division K. May 12, 1999. Gaston J. Fernandez, Judge. Counsel: Meena M. Lopez, Patrick and Lopez, Tampa, for Plaintiff. Vincent Iacono, Law Offices of Howard W. Weber, for Defendant.
Reversed in part; affirmed in part; remanded at 7 Fla. L. Weekly Supp 505b
FINAL SUMMARY JUDGEMENT
THIS CAUSE, having come before the court for hearing on April 26, 1999, upon the Plaintiff’s Motion for Final Summary Judgment, the Court having reviewed the pleadings, depositions, answers to interrogatories, admissions and affidavits on file with the Court, and the Court having heard argument of Counsel, having considered the points and authorities presented, and the Court otherwise being fully advised in the premises and the law, the Court makes the following findings of fact and conclusions of law:
FINDINGS OF FACT
1. GEICO insured Michelle Figueroa under a policy of automobile insurance which complied with the Florida Motor Vehicle No-Fault Law requiring GEICO to pay 80% of reasonable and necessary medical treatment or services rendered to Michelle Figueroa related to an automobile accident of January 16, 1998.
2. On June 26, 1998, GEICO received a bill from Nu-Best Diagnostics, Inc. for the technical component of a videofluoroscopic examination. The total amount of this bill was $650.00. (Deposition of Katherine Sandoval, pages 44-45 and Exhibit 2).
3. On August 3, 1998, GEICO received a bill from William Gatlin, M.D. for the interpretation of the videofluoroscopic examination. The total amount of this bill was $150.00. (Deposition of Katherine Sandoval, p. 62 and Exhibit 5).
4. GEICO submitted the Plaintiff’s medical records for a peer-review performed by Dr. John Kurpa, a chiropractor licensed in the State of Florida. Dr. Kurpa rendered an opinion that the videofluoroscopic procedure was “performed without medical necessity, reasonableness or relatedness to the collision.” Pursuant to Dr. Kurpa’s report, GEICO denied payment of the bills submitted by Nu-Best Diagnostic Labs and William Gatlin, M.D. (Deposition of Katherine Sandoval, pp. 44-52, 61-65 and Exhibits 2 and 5). At no time did Dr. Kurpa or any other doctor perform an actual physical examination of the Plaintiff. Id.
5. On July 7, 1998, GEICO received a bill from Siegfried K. Holz, M.D. for an MRI of Michelle Figueroa’s lumbar spine in the amount of $1,500.00. (Deposition of Katherine Sandoval, pp. 52-60 and Exhibit 3). GEICO’s bill review system recommended $1,470.00 as the amount for this service and GEICO timely paid 80% of $1,470.00. GEICO’s recommended amount was not based upon a medical report of a doctor and was not based on an Independent Medical Examination of Michelle Figueroa. Id.
6. On July 14, 1998, GEICO received a bill from Siegfried Holz, M.D. for an MRI of the lumbar spine performed on Michelle Figueroa in the amount of $1,400.00. (Deposition of Katherine Sandoval, Exhibit 4, pp. 58-61). GEICO’s bill review system recommended $1,340.00 as the reasonable amount for this service and GEICO timely paid 80% of $1,340.00. GEICO’s recommended amount was not based upon a medical report of a doctor and was not based on an independent medical examination of Michelle Figueroa. Id.
7. On August 20, 1998, GEICO received a bill from Andre Roberge, M.D. for an office consultation with Michelle Figueroa in the amount of $500.00. GEICO recommended a reasonable amount of $320.00 for this service and timely paid 80% of $1,340.00. GEICO’s recommended amount was not based upon a medical report of a doctor and was not based upon an independent medical examination of Michelle Figueroa. (Deposition of Katherine Sandoval, Exhibit 6, pp. 66-69).
8. On March 2, 1998, GEICO received a bill from Robert D. Densmore for services provided to Michelle Figueroa in the amount of $75.00. (Deposition of Katherine Sandoval, pp. 40-41). GEICO paid 80% of that amount or $60.00 on April 6, 1998. In addition GEICO paid six days of interest at the statutory rate in the amount of ten cents (.10). (Deposition of Katherine Sandoval, Exhibit 1, pp. 40-43).
9. On March 2, 1998, GEICO received a bill from Robert D. Densmore for services provided to Michelle Figueroa in the amount of $100.00. (Deposition of Katherine Sandoval, pp. 43-44). GEICO paid 80% of that amount or $80.00 on April 6, 1998. In addition GEICO paid six days of interest at the statutory rate in the amount of thirteen cents (.13). (Deposition of Katherine Sandoval, Exhibit 1, pp. 43-44).
CONCLUSIONS OF LAW
1. The Court holds that Section 627.736(7)(a), Florida Statutes (1997) as interpreted by the opinion of United Automobile Insurance Company v. Viles, 24 Fla. L. Weekly D14 (Fla. 3d DCA 1998) requires an insurance company to obtain a report of a physician who conducted an independent medical examination of the insured prior to reducing or denying a medical bill of the insured. Because an independent medical examination is required, a report of a physician based only upon a records review does not meet the actual examination requirement of §627.736(7)(a) and Viles. GEICO’s denials of payment of the bills of Nu-Best Diagnostic and William Gatlin, M.D. pursuant to the peer-review of John Kurpa, D.C., fails to meet this examination requirement, and the denial of these bills was a breach of the policy as a matter of law. In addition, GEICO’s reduction of bills submitted by Siegfried K. Holz, M.D. and Andre Roberge, M.D. without the report of a physician who conducted an independent medical examination were a breach of the policy as a matter of law.
2. The Court finds that Section 627.736(4) and McNally v. Allstate Ins. Co., 5 Fla. L. Weekly Supp. 632 (Fla. 20th Jud.Cir., Collier County May 14, 1998) require an insurance company to pay interest on all overdue payments from that date the bill is received through the date payment is made, not only for the days payment is made in excess of 30 days from receipt. Accordingly, with regard to the bills of Robert D. Densmore, GEICO’s failure to pay interest on the principle amount from March 3 through April 6 violated the statute as a matter of law.
WHEREFORE, the Court finds that the Plaintiff is entitled to judgment as a matter of law, grants the Plaintiff’s Motion for Final Summary Judgment and Plaintiff shall recover from Defendant as follows:
1. With regard to the bill of Nu-Best Diagnostic, the Plaintiff shall recover $520.00 (eighty-percent of $650.00) plus statutory interest at the rate of 10% per year from June 26, 1998, the date the bill was received.
2. With regard to the bill of William Gatlin, M.D., the Plaintiff shall recover $120.00 (eighty-percent of $150.00) plus statutory interest at the rate of 10% per year from August 3, 1998, the date the bill was received.
3. With regard to the bill of Siegfried K. Holz, M.D. for the lumbar MRI, the Plaintiff shall recover $24.00 (eighty-percent of the difference between what was charged and the reduced amount, or $1,500.00 – $1,470.00 = $30 x .8 = $24.00), plus interest at the statutory rate of 10% per year from July 7, 1998, the date the bill was received.
4. With regard to the bill of Siegfried K. Holz, M.D. for the cervical MRI, the Plaintiff shall recover $48.00 (eighty-percent of the difference between what was charged and the reduced amount, or $1,400.00 – $1,340.00 = $60 x .8 = $48.00), plus interest at the statutory rate of 10% per year from July 14, 1998, the date the bill was received.
5. With regard to the bill of Andre Roberge, M.D., the Plaintiff shall recover $144.00 ($500.00 or $340.00 = $160.00 x .8 = $144.00) plus statutory interest at the rate of 10% per year from August 20, 1998, the date the bill was received.
6. With regard to the bills of Robert D. Densmore, the Plaintiff shall recover interest upon the principle amounts at the statutory rate of 10% per year from the date each bill was received, March 2, 1998, to the date each was paid, April 6, 1998.
For which let execution issue.
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