7 Fla. L. Weekly Supp. 745b
Insurance — Personal injury protection — HCFA form submitted by medical provider which contained insured’s name, address and telephone number; claim number assigned by insurer; fact that claim was related to automobile accident; nature of service provided by medical provider, and bill for provider’s service was sufficient to serve as written notice of a covered loss and amount of loss — Upon receipt of HCFA form, burden was on insurer to authenticate claim within thirty days; if insurer could not prove it was not responsible for payment, it should have paid claim within thirty days of date of receipt of HCFA form — Because insurer failed to obtain any proof it was not responsible, plaintiff is now entitled to statutory interest and attorney’s fees and costs — Argument that written notice of covered loss did not occur until receipt of no-fault application is not supported by case law or reasonable interpretation of statute
PINNACLE MEDICAL INC., d/b/a Iso Data Diagnostics, Plaintiff, v. BANKERS INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. SO96-4094. August 16, 2000. Jerry Brewer, Judge. Counsel: Harley N. Kane, Greenspan & Kane, Boca Raton. Brian D. Degailler, Orlando.
ORDER GRANTING SUMMARY JUDGMENT
This action was heard on July 18, 2000 on the Plaintiff’s Motion for Summary Judgment. The Court having read the motion, considered the affidavits, depositions, pleadings and having heard argument of counsel finds as follows:
Findings of Fact
This matter comes to this court following the completion of the appellate process relating to an appeal of a non-final order denying the defendant’s motion to compel arbitration and declaring the arbitration provision of F.S. 627.736(5) unconstitutional. Nationwide Mutual Ins. Co. v. Pinnacle Medical, Inc., 753 So.2d 55 (2000). This summary judgment disposes of the merits of the matter. On June 3, 1996, Eval Luxim was the passenger in a motor vehicle involved in a motor vehicle accident in which Mr. Luxim was injured. The vehicle was owned and operated by the defendant’s named insured. Mr. Luxim did not own a motor vehicle or live with a relative who owned a motor vehicle. As such, pursuant to F.S. 627.736 Mr. Luxim was entitled to P.I.P. benefits under the named insured’s policy with the defendant. Following the accident Mr. Luxim sought treatment for his injuries at Colonial Chiropractic. His doctor there ordered certain diagnostic tests which were performed by the Plaintiff. A bill for the plaintiff’s services was submitted on a HCFA 1500A form together with the medical report relating to the diagnostic testing which the defendant received on June 26, 1996. That bill included the following information:
1. Mr. Luxim’s name, address and phone number,
2. the claim number assigned by the defendant to this claim,
3. the fact that this claim was related to an automobile accident,
4. the nature of the service provided by the plaintiff,
5. the bill for the plaintiff’s services.
The defendant did nothing with the bill until July 12, 1996 when the claim was assigned to an adjuster. The adjuster opened the claim and mailed certain paperwork to Mr. Luxim. The defendant’s position was that it could not extend coverage until it had proof Mr. Luxim did not own a motor vehicle or live with a relative who owned a motor vehicle. It was not until July 24th, 1996 that the adjuster called both their named insured and Mr. Luxim at the number listed on the HCFA form. Although the adjuster did not contact either their named insured or Mr. Luxim on that date, a message was left at both locations. On July 30, 1996 the named insured called the adjuster back and informed the defendant that Mr. Luxim did not own a motor vehicle or live with any relatives who owned motor vehicles. The defendant still refused to pay the plaintiff’s claim until it received a “no-fault application”. On August 12, 1996 the defendant received an executed “no-fault application” signed by Mr. Luxim confirming the information previously communicated on July 30th, 1996 by the named insured. The defendant still did nothing with the claim for 30 days. On August 30, 1996 the plaintiff filed this suit, which was served on the defendant by the department of insurance on September 9th, 1996. On September 11th, 1996 the defendant paid 80% of the charges submitted by the plaintiff. The defendant asserts that it owes neither statutory interest nor attorney fees because it issued payment on the 30th day following receipt of the “no-fault application” which it claims is when it had “notice” this was a “covered loss”. The plaintiff asserts that the defendant owes both interest and attorney fees because it failed to pay within 30 days of receiving notice of a covered loss and the amount thereof. The plaintiff asserts that the defendant received such notice on July 26th, 1996, the date the defendant received the HCFA form.
Conclusions of Law
This case is resolved by the language contained in F.S. 627.736(4)(b) which states:
. . . personal injury protection benefits paid pursuant to the section shall be overdue if not paid within thirty days after the insurer is furnished with written notice of a covered loss and the amount of same.
There is no dispute that the benefits claimed by the plaintiff was a “covered loss” as the defendant issued payment for 80% (the percentage mandated by the PIP statute) on September 11, 1996. The defendant received written notice and the amount of the covered loss on June 26, 1996 when it received the HCFA 1500A form from the Plaintiff. The defendant’s position that its “written notice of a covered loss” did not occur until receipt of the “no-fault application” is not supported by any case law or reasonable interpretation of F.S. 627.736(4)(b). Whereas the plaintiff’s position is supported by the plain meaning of the statute as well as a number of appellate decisions. Notice has been described as “[w]hatever is sufficient to put a person on inquiry amounts in point of law to notice, provided the inquiry becomes a duty and could lead to knowledge of the facts by the exercise of ordinary intelligence and understanding.” Farish v. Smoot, 58 So.2d 534 (Fla. 1952). Here, such a duty arose when the defendant received a HCFA form from the defendant which possessed sufficient information for the adjuster to begin an inquiry.
The most compelling opinion relating to this matter is New Hampshire Indemnity Company v. Pinnacle Medical, Inc., 4 Fla. L. Weekly Supp. 753 (Fla. 9th Jud. Cir. 1997) which is analogous to this case. The New Hampshire Indemnity case is an appellate decision here in the 9th judicial circuit and is therefore binding on this court. Fieselman v. State, 566 So.2d 768 (Fla. 1990). In New Hampshire, Judge Stroker held as follows:
“In the instant case, the HCFA form indicates that Merilus’ condition was related to an auto accident; it indicates a date which is either the date of the injury or the date Merilus first noticed symptoms of the injury; it contains the name, address, telephone number, date of birth, and `I.D. NUMBER’ of the insured; and it contains the amount of the loss. Additionally, and most importantly, the trial court found that the number listed in the space on the HCFA form called “INSURED’S POLICY GROUP OR FECA NUMBER” was actually the claim number that New Hampshire had assigned to the claim by New Hampshire indicates that New Hampshire had already been notified of the accident by its insured. Although the information contained on the HCFA form does not include specific details about the accident, it does contain sufficient information to constitute “written notice” under section 627.736(4)(b). Thus, upon receipt of the HCFA form, the burden was on New Hampshire to authenticate the claim within thirty days; if New Hampshire could not prove it was not responsible for the payment, it should have paid the claim within thirty days of the date of receipt of the HCFA form.”
The instant case is analogous to New Hampshire Indemnity. The HCFA form submitted to the defendant here contained all the same information as the HCFA form in New Hampshire Indemnity. Thus, upon receipt of the HCFA form, the burden was on the defendant to authenticate the claim within thirty days; if the defendant could not prove it was not responsible for the payment, it should have paid the claim within thirty days of the date of receipt of the HCFA form. It obviously failed to obtain any proof it was not responsible and therefore is now responsible for statutory interest and attorney fees and costs.
This court is also persuaded by the other cases cited by the plaintiff and which served as the underpinnings of New Hampshire Indemnity. In Dunmore v. Interstate Fire Ins. Co., 301 So.2d 502 (Fla. 1st DCA 1974), the first district held that the insurer was obligated to pay within thirty days of written notice of a claim. The Court in Dunmore stated:
“It appears to us that the statutory language is clear and unambiguous. The insurance company has thirty days in which to verify the claim after receipt of an application for benefits. There is no provision in the statute to toll this time limitation. The burden is clearly upon the insurer to authenticate the claim within the statutory time period”. Id.
This court must reject the defendant’s attempt to shift the burden of proof to Mr. Luxim. The burden to investigate and authenticate the claim rests solely with the defendant. The Third District approved of and adopted Dunmore in Crooks v. State Farm, 659 So.2d 1266 (Fla. 3rd DCA 1995). There, the court read the plain meaning of the statute to only require written notice of the loss, not necessarily on the insurance company’s PIP application form. Crooks directly addresses the issue faced in this case: Crooks was involved in an automobile accident and as a result underwent medical treatment and incurred several medical bills. Crooks, through his attorney, wrote a letter to State Farm, simply listing the itemized bills for three medical providers who had yet to be paid, and requesting State Farm to pay these bills within thirty days of receipt of the letter. State Farm thereafter failed to pay Crooks’ medical bills within thirty days of receipt of the letter. State Farm maintained that it would not recognize the claims until they were submitted on a particular in house claim form. This is the same position which the defendant is taking in this case.
That Court ruled that the insurer had clearly violated the express requirements of Section 627.736(4)(b) by failing to pay Crooks’ medical bills within thirty days of being notified, in writing of the charges. Id. There, a letter to the insurer itemizing the bills incurred was sufficient to serve as “written notice of a covered loss and the amount of the loss.” Id. Apparently, the letter to the insurer in Crooks contained the same, or possibly even less information as was supplied by the HCFA form in this case. Clearly, if a letter listing itemized bills to an insurer can serve as sufficient written notice under F.S. 627.736(4)(b), so can a HCFA form as in the instant case.
This court finds that the facts in this matter are analogous to the facts in New Hampshire Indemnity and therefore GRANTS the plaintiff’s motion for summary judgment. The plaintiff is entitled to interest on the principal amount of $520.00 from June 25, 1996 through September 11, 1996 which is Seventy-Eight (78) days in the amount of $11.11. And prejudgment interest on the $11.11 figure from September 11, 1996 through July 20, 2000 which is three (3) years and three hundred thirteen days (313) in the amount of $4.29 for a total of $15.40. The plaintiff is also entitled to attorney fees and costs for this action. The court reserves jurisdiction to determine the amount at a later time.
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