Volume 12

12 Fla. L. Weekly Supp. 490a

Insurance — Personal injury protection — Coverage — Denial — Unreasonable, unnecessary or unrelated medical expenses — Reasonable proof within thirty days — While insurer does not lose right to contest whether bill is reasonable, related and necessary if it fails to obtain reasonable proof within 30 days of receipt, insurer must obtain medical report before it can thereafter withdraw benefits — Where more than 30 days after receipt of bills for medical and chiropractic treatment insurer obtained peer review by chiropractor opining that some chiropractic treatment was excessive, and insured’s motion for summary judgment does not argue that insurer withdrew benefits before it obtained medical report or establish that no dispute exists as to whether insurer failed to obtain medical report before withdrawing benefits, insured is entitled to summary judgment as to all medical bills but is entitled to summary judgment only as to that portion of chiropractic bills not controverted by peer review

12 Fla. L. Weekly Supp. 673c

Insurance — Personal injury protection — Coverage — Denial — Independent medical examination — Failure to attend — Where medical provider agreed to reschedule IME at request of insured’s attorney, insurer is prohibited from using first IME date as date of suspension of benefits — Where insured unreasonably failed to attend second scheduled IME, insurer is not obligated to pay medical bills received after insured’s nonattendance but is required to pay bills received prior to nonattendance — Notice of loss — Failure of insured to provide notice of loss until sixteen days after accident is insufficient to deny payment where insured provided notice of claim as soon as practicable and, even if notice was late, there is no allegation that insurer was prejudiced by late notice — Summary judgment granted in favor of medical provider

12 Fla. L. Weekly Supp. 491a

Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Insurer’s motion for summary judgment arguing that medical provider’s noncompliance with EOB request for records and information constitutes failure to satisfy condition precedent to suit is denied where there is factual issue as to whether insurer requested additional information within 30 days of receipt of invoices — Insurer is entitled to partial summary judgment as to facts that information was requested and that provider failed to provide anything in response to request

12 Fla. L. Weekly Supp. 491a

Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Insurer’s motion for summary judgment arguing that medical provider’s noncompliance with EOB request for records and information constitutes failure to satisfy condition precedent to suit is denied where there is factual issue as to whether insurer requested additional information within 30 days of receipt of invoices — Insurer is entitled to partial summary judgment as to facts that information was requested and that provider failed to provide anything in response to request

12 Fla. L. Weekly Supp. 983a

Insurance — Personal injury protection — Coverage — Denial — Unreasonable, unrelated or unnecessary expenses — Failure to obtain reasonable proof within 30 days — Where insurer’s failure to pay PIP benefits or provide explanation of benefits explaining reason for denial of payment within 30 days of receipt of notice of claim shows insurer did not have reasonable proof to deny payment within 30-day statutory period, insurer is precluded from asserting defense that treatment was not reasonable, related or necessary

12 Fla. L. Weekly Supp. 452a

Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — No error in finding insurer breached contract by failing to provide EOB for reduced or rejected claims without requiring medical provider to prove underlying treatment was reasonable and necessary

12 Fla. L. Weekly Supp. 391a

Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Medical provider/assignee’s claim for breach of contract for not providing adequate EOB — Date of loss, date of claim, date of service, and amount of claim are sufficient “itemization” where complete denial of claim is made — However, where insurer failed to specify reason for denial, insurer’s responses failed to meet “specification” requirement of section 627.736(4)(b) — As section 627.736(4)(b) has become part of PIP insurance contract, provider is entitled to assert insurer’s failure to provide required EOB as separate cause of action for breach of contract — Summary judgment granted in favor of provider

12 Fla. L. Weekly Supp. 391a

Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Medical provider/assignee’s claim for breach of contract for not providing adequate EOB — Date of loss, date of claim, date of service, and amount of claim are sufficient “itemization” where complete denial of claim is made — However, where insurer failed to specify reason for denial, insurer’s responses failed to meet “specification” requirement of section 627.736(4)(b) — As section 627.736(4)(b) has become part of PIP insurance contract, provider is entitled to assert insurer’s failure to provide required EOB as separate cause of action for breach of contract — Summary judgment granted in favor of provider

12 Fla. L. Weekly Supp. 396a

Insurance — Personal injury protection — Coverage — Denial — Explanation of benefits — Form response letter that cites to various subsections of section 627.736, but does not explain which provisions apply, how medical provider violated statute, and what is needed to process claim is not legally sufficient EOB — Partial summary judgment entered in favor of provider on claim of entitlement to EOB and attorney’s fees

12 Fla. L. Weekly Supp. 372a

NOT FINAL VERSION OF OPINION
Subsequent Changes at 12 Fla. L. Weekly Supp. 970a

Insurance — Personal injury protection — Coverage — Medical expenses — Reasonable, related and necessary treatment — Summary judgment — Affidavit of peer review physician and attached peer review report is not competent evidence that would create genuine issue of material fact where affidavit is conclusory and does not state physician’s opinion or basis of opinion with regard to propriety of treatment, but merely authenticates peer review report, which is inadmissible as document created for sole purpose of litigation — Peer review report is not valid report allowing insurer to withhold benefits on grounds of medical report where report was not obtained prior to withholding benefits and is not factually supported by physical examination — Insurer’s failure to pay benefits within thirty days does not bar insurer from posing other defenses, such as late notice — Summary judgment granted in favor of provider with respect to whether treatment was reasonable, related and necessary