7 Fla. L. Weekly Supp. 620b
Insurance — Personal injury protection — Insurer, who seeks to reduce amount paid for medical treatment based upon unreasonableness of charge, need not obtain a report from physician licensed under same chapter as treating physician stating that treatment was not reasonable, related or necessary, before paying claim at amount less than amount billed — Where medical providers were paid substantial portion of claims in timely fashion and only a portion of bill was denied because it was determined that charges exceeded reasonable and customary charges for particular geographic region, report is not required
SHANNON ADAMS, Plaintiff, vs. STATE FARM MUTUAL AUTO INSURANCE CO., Defendant. County Court, 12th Judicial Circuit in and for Manatee County, Civil Division. Case No. 2000-SC-616. June 28, 2000. Matthew E. McMillan, Judge.
ORDER ON DEFENDANT’S MOTION IN LIMINE
THIS CAUSE having come on to be heard on Defendant’s Motion for Partial Summary Judgment/Motion in Limine and the Court having considered the Motion and being otherwise duly advised in the premises, finds as follows:
State Farm files this Motion for Partial Summary Judgment/Motion in Limine based upon Florida Statutes § 627.736(1)(a) and (5) and United Automobile Insurance Company v. Viles, 726 So.2d 320 (Fla. 3rd DCA 1998). (Hereinafter referred to as “Viles”). The Plaintiff contends that the Defendant reduced the amount of benefits paid under PIP benefits and did so without procuring a report from a doctor as required by the statute. The Defendant argues that they did not reduce the amounts paid because the treatment was not reasonable, but because the amount of the treatment charged by the doctor was not reasonable. The Defendant argues that it is senseless to require a report from a medical doctor under these circumstances.
Florida Statutes § 627.736(7)(a) provides as follows:
“Whenever the mental or physical condition of an injured person covered by personal injury protection is material to any claim that has been or may be made for past or future personal injury protection insurance benefits, such person shall, upon the request of an insurer, submit to mental or physical examination by a physician or physicians….An insurer may not withdraw payment of a treating physician without the consent of the injured person covered by the personal injury protection, unless the insurer first obtains a report by a physician licensed under the same chapter as the treating physician whose treatment authorization is sought to be withdrawn, stating that treatment was not reasonable, related, or necessary.” (Emphasis Added)
In Viles, the Plaintiff filed suit seeking PIP benefits for injuries sustained in an accident. The insurer answered and affirmatively defended that the chiropractic bills in question were fraudulent and were not reasonably related to the accident.
Ultimately the trial court certified a question to the Third District Court of Appeal:
“In any claim for personal injury protection benefits in which the insurance carrier has withdrawn, reduced benefits or denied further benefits, is it a condition precedent to Section 627.736(7)(a), Florida Statutes, that an insurer obtain a report by a physician licensed under the same chapter as the treating physician stating that the treatment was not reasonable, related or necessary in order for the insurance carrier to defend a suit for reduction, withdrawal or denial of further payments on the grounds of reasonableness, necessity or relationship?”
The Third District answered the certified question in the affirmative. The Court quoted Derius v. Allstate Indemnity Company as precedent which states as follows:
“This language is part of the independent medical examination requirement of section 627.736(7) which is “intended to give insurers an opportunity to determine the legitimacy of a claim so that an appropriate decision can be made as to whether benefits should be paid.” U.S. Security Ins. Co. v. Silva, 693 So.2d 593 (Fla. 3rd DCA 1997). The quoted language from section 627.736(7)(a) sets up a procedural requirement that an insurer cannot withdraw payment of a treating physician unless the decision is supported by an expert that the treatment does not comply with the statutory criteria.” 23 Fla. L. Weekly D1383 (Fla. 4th DCA 1998)
The intent of the statute is well served by the requirement that the insurer obtain the report of a physician licensed under the same chapter as the treating physician stating that the treatment was not reasonable, related or necessary. This protects the insured and allows the insurer to evaluate claims properly, and likewise protects the insurer from having to pay for unnecessary, unrelated or unreasonable treatment.
However, it would seem that the statute specifically states that a report need only be obtained when the insurer seeks to withdraw, reduce, or deny benefits when the insurer asserts that the “treatment was not reasonable…” The statute does not require such a report when the insurer asserts that the cost of the treatment is not reasonable. The reductions contemplated by the Viles decision would appear to be related to a reduction in the amount of benefits paid, not a reduction in the amount of a physician’s individual bill. For example then, the insurer is asserting that, although the treatment modality is acceptable, the cost billed is not. The insurer is therefore not saying that the insured cannot receive more treatments, but that the treatments will only be paid up to a certain cost. Hence, the pool of benefits has not been reduced.
Viles states that “[S]tatutes will not be interpreted in a manner that leads to an unreasonable result or a result obviously not intended by the legislature.” Viles at 321. It would appear to this court that to require such a report, as is contemplated section 627.736(7)(a), would be an unreasonable construction of the statute. To require such a report would be meaningless. Would a comparably licensed physician be required to say that another physician’s bills were unreasonable, or that the price he charges for a particular treatment modality is excessive? Certainly the legislature could not have intended such a result.
The Viles decision also reminds us that Florida’s No Fault laws are to be liberally construed in favor of the insured. Viles at 321. However, how would such a requirement favor the insured? It would seem that the report would be somewhat meaningless, and the requirement would have little benefit, except that the insurer may forego reducing or denying benefits when the amounts are small due to the expense of an independent medical report.
The legislative intent of the statute is to expedite the payment of PIP claims. In the cases before us, the medical providers were paid a substantial portion of the claims in a timely fashion. Only a portion of the bill was denied because “Based on review, it was determined that the charges exceed the reasonable and customary charges for this geographic region.” It would appear that the intent of the statute has been substantially complied with. Certainly the legislature could not have intended that the insurer pay whatever a medical provider billed for a service that is reasonable, necessary, and related. There must be some mechanism for the insurer to protect itself, and thus all consumers, from overcharging for services by medical providers.
Judge Krista Marx of Palm Beach County was faced with the same issue in the case of Schall v. Allstate Insurance Company, 7 Fla. L. Weekly Supp. 63 (1999). Judge Marx distinguished the Viles decision, stating that the issue in Viles was a cut-off or discontinuation of benefits and should be contrasted with a decision to adjust or reduce the amount of a bill. The Court noted that the report requirement discussed in the Viles decision was based upon F.S. 627.736(7)(a), and that reductions of payments are controlled by F.S. 627.736(1)(a). (“Eighty percent of all reasonable expenses for necessary medical, surgical, X-Ray, dental, and rehabilitative services,…”) Judge Marx concluded that under circumstances where the insurer seeks to reduce the amount paid because of the reasonableness of the amount of the bill, such a report is not required.
This Court agrees with the analysis of Judge Marx, who certified a question of great public importance to the Fourth District Court of Appeal:
Must an insurance company, who seeks to reduce bills for medical treatment, pursuant to Section 627.736(1)(a), first obtain a report from a physician licensed under the same licensing chapter as the treating physician stating that the bills for treatment are not reasonable, pursuant to Section 627.736(7)(a)?
Although the Fourth District has yet to answer the question, this Court finds that the answer should be answered in the negative and follows Judge Marx’ decision in Schall.
In Progressive Specialty Insurance Company v. Biomedical Trauma Association, Inc., 7 Fla. L. Weekly Supp. 389 (Fla. 13th Judicial Circuit, March 13, 2000), the Court held that the Viles decision would require such a report. The Court goes on to say that if no such report were required, “an insurance company could pay a small portion of a contested bill (paying $10 on an $800 bill, for example) and avoid the statute.” This Court is not persuaded by such an argument. Courts are to construe statutes as they are written, and not create some construction of a statute because of some possible eventuality. Additionally, attorney’s fees would seem to be cost prohibitive of such a practice.
ORDERED AND ADJUDGED that the Defendant’s Motion is granted, and that the Defendant need not obtain a report from a physician licensed under the same chapter as required in section 627.736(7)(a) before paying a claim at an amount less than the amount billed upon a contention that the charge was unreasonable under section 627.736(1)(a) and (5).
IT IS FURTHER ORDERED AND ADJUDGED that this Court recedes from any previous rulings of the Court to the extent that this opinion conflicts.
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