9 Fla. L. Weekly Supp. 397b
Insurance — Personal injury protection — Medical expenses — Section 627.736(5)(a) and (d) do not require the HCFA form to be countersigned by the insured if the medical provider has accepted an assignment of benefits
HEALTH CARE ASSOCIATES OF SOUTH FLORIDA, INC., and MIAMI MEDICAL GROUP, INC. (as Assignees of CARIDAD VALDES DILME), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Dade County, Civil Division. Case No. 01-16172 CC05. March 12, 2002. A. Leo Adderly, Judge. Counsel: Jacob Jackson. Carlos A. Lopez, Jr., Lopez & Best, Miami.
ORDER DENYING DEFENDANT’S MOTIONFOR SUMMARY JUDGMENT
THIS CAUSE came on before the Court on March 8, 2002, on Defendant’s Motion for Summary Judgment and the Court having heard argument of counsel, having reviewed the pleadings and memoranda and being otherwise fully advised in the premises, it is
ORDERED AND ADJUDGED that Defendant’s Motion for Summary Judgment is hereby DENIED based upon the following grounds.
FACTS OF CASE
Defendant’s undisputed facts acknowledge that there was an accident covered by Defendant, United Automobile Insurance Company’s policy, injuries sustained by the insured, medical treatment rendered to the insured by the Plaintiff Medical Provider, an assignment of benefits given by the insurer to the Plaintiff, and bills timely submitted on Health Care Finance Administration 1500 (HCFA) forms that were received by Defendant. It is undisputed that Defendant has not paid any of the medical bills incurred by its insured. The only issue before the Court is whether Defendant can claim that it did not “receive timely notification” of the claim because the HCFA forms were not countersigned by its insured who gave the Plaintiff Medical Provider an irrevocable assignment, thereby relinquishing any right, title, interest or ownership in the claim.
Defendant filed a Motion for Summary Judgment predicated upon F.S. §627.736(5)(a)&(d), claiming that it did not have an obligation to pay for the medical services provided to its insured by the Plaintiff because the Plaintiff failed to have the insured countersign each and every HCFA form submitted to Defendant. The Court disagrees with the Defendant’s interpretation and application of F.S. §627.736(5)(a)&(d).
F.S. §627.736(5)(a) IS INAPPLICABLE TO BENEFITS THAT HAVE BEEN ASSIGNED
F.S. §627.736(5)(a) is inapplicable to payment of benefits that have been assigned. The significance of the act of assignment renders moot and inapplicable the very provision of F.S. §627.736(5)(a) upon which Defendant seeks to rely. F.S. §627.736(5)(a) is a provision that allows, at the insurer’s sole discretion, the choice to pay the insured for the PIP benefits due, or alternatively, to pay the medical provider directly, for the PIP benefits due and owing on behalf of the insured. Because, and only because, the insured still “owns” the claim for PIP benefits and the medical provider lacks standing to sue directly for payment of the services it has rendered because it does not “own” the claim, the insurer is provided with a procedure by which it can pay the medical provider, if it chooses, thereby ensuring that the person or entity who actually provided the service giving rise to the PIP benefits is in fact the person or entity that receives the payment.1
However, because the insured still “owns” the claim, and the medical provider has no direct cause of action for payment, if the insurer pays the medical provider without first confirming with the insured that the insured actually received the services from the medical provider in question, the insurer opens itself up to a problem of paying for services never rendered and using up available PIP benefits otherwise due to the insured.
To avoid this problem, the insurer has the insured countersign the HCFA forms submitted to it by the medical provider as an acknowledgement that the services were in fact rendered. By signing the HCFA forms, the insurer is in no way obligated to pay the medical provider directly. In fact, if the insured signs the HCFA forms and specifically asks the insurer to pay his or her medical provider directly, the insurer may choose to say “No” and may choose to pay the insured directly. In short, the insurer controls whether to exercise its option to pay the insured or the medical provider directly once the requirements of F.S. §627.736(5)(a) are met.
But, once the claim is assigned to the medical provider, the insured no longer can receive the payment for the PIP benefits directly. The insured loses his or her right to payment. The insured no longer “owns” the claim and the insurer no longer has any choice to decide whether to pay the insured or the medical provider. The assignment of benefits decides the issue for the insured and the insurer and the insurer are now bound to pay only the medical provider who now “owns” the claim and is alone entitled to payment.
Moreover, the entire reason for the insured’s signature on each and every HCFA form no longer exists. The insurer does not need proof from the insurer that it is authorized to pay the medical provider directly because the assignment of benefits decides that issue for the insured and the insurer. The insured, by virtue of assigning the benefits to the medical provider is, a priori, acknowledging that the medical provider provided the services rendered. The medical provider is now alone entitled to be paid for them. Clearly, under the laws governing assignments, the medical provider stands in the shoes of the insured and alone is entitled to payment. Since F.S. §627.736(5)(a) contemplates payment to either the insured or the medical provider after conditions precedent are met, it cannot by law and common sense be applicable to situations arising where an assignment of benefits has occurred. The insured CANNOT be paid the benefits once they are assigned to the medical provider. Therefore, F.S. §627.736(5)(a) does not apply to the situation at bar.
Defendant’s attempt to read F.S. §627.736(5)(a) and F.S. §627.736(5)(d) together and to bind one statutory provision to the other is misplaced. F.S. §627.736(5)(d) only states that certain forms must be used in order to submit a claim to the insurer. The HCFA forms used in the present case comply with the requirements of the statute. The statute makes absolutely no reference to countersignatures of the insured. Defendant seeks to read into the statute what is not there. There is no requirement that the insured must sign each and every HCFA form or other form authorized in order to receive payment for the benefits due and owing. Once there is a signature filed with the medical provider by the insured authorizing medical treatment, the filling out of the HCFA forms to be sent to the medical provider is ministerial in nature. The insurer is clearly and unequivocally on notice of the claim, which is the purpose and intent of the HCFA forms. Defendant’s attempt to controvert the purpose and intent of the statute to provide swift payment for medical services needed by an insured when injured in an automobile accident regardless of fault cannot be subverted by Defendant’s attempt to create a technical Catch 22 to allow the insurer to fail to meet its responsibilities to pay for medical benefits that are reasonable, related and medically necessary.
In fact, a statute will not be interpreted in a manner that leads to an unreasonable or ridiculous result or a result obviously not intended by the Legislature. United Automobile Insurance Company v. Viles, 726 So.2d 320 (Fla. 3rd DCA 1999). Defendant’s argument is premised upon an illogical fallacy that if the insurer “MAY” pay the Plaintiff directly when the medical bills are countersigned, then the opposite is true, i.e. the insurer “MAY NOT” pay the medical provider when the bills are not countersigned. Such an interpretation of F.S. §627.736(5)(a) by Defendant has indeed resulted in an interpretation that leads to an unreasonable or ridiculous result not intended by the Legislature.
Based upon the foregoing, the Court concludes that F.S. §627.736(5)(a)&(d) do not require the HCFA form to be countersigned by the insured if the medical provider has accepted an assignment of benefits.
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1An assignment of the insured’s interest in personal injury protection benefits to a medical provider is irrevocable. Rittman v. Allstate Insurance Co., 727 So.2d 391 (Fla. 1st DCA 1999); State Farm Automobile Insurance Company v. Gonel1a, 677 So.2d 1355, 1356-57 (Fla. 5th DCA 1995); State Farm Fire and Casualty Company v. Ray, 556 So.2d 811, 813 (Fla. 5th DCA 1990) (“Because an unqualified assignment transfers to the assignee all the interest of the assignor under the assigned contract, the assignor has no right to make any claim on the contract once the assignment is complete, unless authorized to do so by the assignee”).
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