Volume 13

13 Fla. L. Weekly Supp. 420a

Insurance — Personal injury protection — Coverage — Medical bills and liens paid by insured — Where insured did not comply with statutory requirement to submit to PIP insurer, on properly completed form, claims for personally paid medical bills and Medicare lien, insurer did not have notice of covered loss, PIP benefits were not overdue, and insured did not have cause of action under PIP statute — Federal law which gives Medicare ability to seek reimbursement from PIP insurer for bills paid by Medicare does not give insured who satisfied Medicare lien ability to seek reimbursement from insurer — Insured has no cause of action against PIP insurer for health insurance lien where claim was not submitted on properly completed form, and health insurance was reimbursed from jury award to insured that included past medical expenses, such that reimbursement of insured by PIP insurer would result in windfall

13 Fla. L. Weekly Supp. 558a

Insurance — Personal injury protection — Coverage — Medical expenses — Failure to pay or obtain reasonable proof within 30 days — Error to enter summary judgment in favor of medical provider where penalty for not paying valid claim or obtaining reasonable proof that claim is not valid within 30-day authentication period is imposition of additional interest and attorney’s fees, not elimination of insurer’s right to contest claim — Reasonable charges — No merit to argument that insurer’s responses to request for admissions establish that charges are reasonable — Statements in admissions relating to payments made to other providers in same zip code as provider and under similar CPT codes do not require conclusion that disputed charges are reasonable — Further, insurer is entitled to rely on computer-based program to contest reasonableness of charges and have jury weigh both parties’ proof

13 Fla. L. Weekly Supp. 908c

Insurance — Personal injury protection — Coverage — Medical expenses — Overdue bills — Explanation of benefits — Tolling of period to pay or reject claim — Where insurer made timely request for x-ray reports to support claims for x-rays and received no response from medical provider, claims were not overdue at time of filing complaint, and suit is premature

13 Fla. L. Weekly Supp. 1154a

Insurance — Personal injury protection — Coverage — Medical benefits — Expert neurological consultation — Usual and customary charges — Evidence — Error to permit insurer’s witness to give opinions as a billing expert although he admitted during testimony that he was not a billing expert and did not do his own billing — Jury could have used this improper testimony in arriving at their verdict — Because of this testimony, it was also error to prohibit provider’s billing specialist from testifying as to codes and fee guide — Provider also should have been allowed to introduce redacted explanation of benefits statements showing amounts insurer had previously paid for the same service — New trial required

13 Fla. L. Weekly Supp. 612a

Insurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Subsequent claim for unpaid portion of bill — Exhaustion of benefits after insurer is on notice that medical provider is pursuing claim for underpaid bills will not shield insurer from liability for those bills — Further, insurer is precluded from arguing exhaustion defense where insurer failed to raise issue of exhaustion of benefits until more than one year after exhaustion had occurred, insurer raised issue in motion for summary judgment without amending affirmative defenses to allege exhaustion defense, and delay was prejudicial — No merit to claim that affirmative defense stating that insurer’s liability, if any, is governed by terms, conditions and limitations of policy pleads exhaustion of benefits because this defense was raised months before exhaustion occurred

13 Fla. L. Weekly Supp. 718b

Insurance — Personal injury protection — Coverage — Exhaustion of policy limits — Subsequent claim for unpaid portion of bills — Where PIP benefits were exhausted prior to medical provider filing suit for unpaid portion of reduced bills, and provider does not allege bad faith or inappropriate bill processing, provider is not entitled to recover benefits or statutory penalties

13 Fla. L. Weekly Supp. 744a

Insurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Where insurer’s overpayment of insured’s lost wages claim resulted in premature exhaustion of benefits, and medical provider’s claim was submitted prior to lost wages claim and exhaustion of benefits, insurer is liable to provider for amount of overpayment so long as provider is able to establish that benefits claimed were reasonable, related and necessary

13 Fla. L. Weekly Supp. 489b

Insurance — Personal injury protection — Coverage — Medical expenses — Nerve conduction testing — Only NCV that is exclusively and entirely performed by physician can be reimbursed at higher Medicare rate — NCV performed by physician’s assistant is compensated at lower workers’ compensation rate

13 Fla. L. Weekly Supp. 345b

Insurance — Personal injury protection — Coverage — Medical expenses — Nerve conduction testing — Where NCV done in conjunction with needle electromyography was physically performed by physicians assistant working under medical provider’s license, test is not reimbursable at 200% of Medicare Part B rate, but at lower workers’ compensation fee schedule rate — Where amount insurer is entitled to recoup for overpayment for NCV far exceeds amount provider seeks in suit, provider cannot prevail, and insurer’s motion for summary disposition is granted

13 Fla. L. Weekly Supp. 375a

Insurance — Personal injury protection — Coverage — Medical expenses — Needle electromyography — Sections 627.736(5)(b)3 and 4 which provide that charge for nerve conduction testing may be reduced to workers’ compensation fee schedule when testing is performed in conjunction with needle EMG does not permit insurer to reduce needle EMG charge