Volume 13

13 Fla. L. Weekly Supp. 375b

Insurance — Personal injury protection — Coverage — Medical expenses — Re-read and interpretation of diagnostic studies — Unbundling from office visit — Where re-reading and interpreting diagnostic studies is not included in office visit CPT code and not included in levels of evaluation and management services, medical provider did not unbundle CPT codes for re-reading and interpreting MRI and x-rays from office visit code — CPT guidelines pertaining to re-reading and interpreting diagnostic studies do not restrict medical provider from billing for re-reading and interpreting studies ordered by another provider

13 Fla. L. Weekly Supp. 179a

Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Insurer improperly denied payment for re-reading and interpretation of previously taken lumbar MRI and cervical and lumbar x-rays based on insurer’s belief that those charges were built into provider’s initial office visit, CPT code 99245, billed on same date — Applicable American Medical Association Current Procedural Terminology did not say that reading and interpretation of MRI and x-ray films was included within CPT Code 99245 — Actual interpretation of diagnostic tests/studies is not included in levels of evaluation/management services — There is no requirement that physician doing re-read must have ordered diagnostic studies during a patient encounter — Provider’s motion for summary judgment granted 

13 Fla. L. Weekly Supp. 1233a

Insurance — Personal injury protection — Examination under oath — Failure to attend — Insured did not unreasonably refuse to attend EUO where insured’s attorney requested that insurer reschedule EUO that had been unilaterally scheduled for minor at time parent was unavailable to attend, and insurer never responded to attorney’s request — Claim form — Acknowledgment and disclosure form — Where medical provider’s self-generated acknowledgment and disclosure form includes all language specified by section 627.736(5)(e) and identifies specific services rendered, form substantially complies with statute despite failure to use specific form generated by state

13 Fla. L. Weekly Supp. 366a

Insurance — Personal injury protection — Misrepresentation — Insurer met its burden of proving non-existence of genuine issue of fact as to medical provider’s misrepresentation of services by introducing insured’s examination under oath in which insured denied having done or been taught exercises, affidavits of litigation specialist, and HCFA forms establishing that services were not rendered — Provider did not file anything in opposition to raise genuine issue of material fact — Misrepresentation voids entire claim — Further, insurer is not responsible for payment of bills that were untimely submitted — Insurer’s motion for final summary judgment grantedREVERSED in part at 14 Fla. L. Weekly Supp. 1089a

13 Fla. L. Weekly Supp. 796c

Insurance — Personal injury protection — Misrepresentations — Claims investigation — Where PIP policy excludes coverage “if you or insured person has concealed or misrepresented any material fact or circumstance or engaged in fraudulent conduct in connection with presentation or settlement of claim,” statute in effect at time of loss gave insurers discretion to exclude coverage for misrepresentation or fraud, and insured made misrepresentations during investigation of claim of person injured while repairing insured’s vehicle in insured’s garage, insurer was not obligated to cover claim despite fact that injured claimant did not make misrepresentations and misrepresentations occurred during investigation of claim

13 Fla. L. Weekly Supp. 341a

Insurance — Personal injury protection — Exhaustion of policy limits — Where PIP benefits were used to pay both lost wages and medical expenses and insured did not request that remainder of PIP benefits be reserved for paying lost wages until shortly before PIP policy limits were exhausted, and policy contains endorsement that expressly provides that medical payment coverage is excess to PIP coverage and, aside from co-pay not paid by PIP, not available until all medical expense benefits under PIP coverage have been exhausted, insurer had no duty to retroactively reallocate medical expenses previously paid by PIP to medical payment coverage after all PIP coverage had been exhausted

13 Fla. L. Weekly Supp. 124a

Insurance — Personal injury protection — Claims — Timeliness — Where medical provider never submitted MRI bill to insurer, and bill was submitted by insured’s attorney five months after treatment was rendered, trial court correctly concluded that medical provider lost right to be paid for MRI — Med pay — Error to enter summary final judgment in favor of insurer where, in absence of statutory or contractual restriction, insured may be entitled to recover from med pay coverage the 20% of MRI bill that would have remained unpaid by PIP had claim been properly submitted

13 Fla. L. Weekly Supp. 10a

NOT FINAL VERSION OF OPINION
Subsequent Changes at 13 Fla. L. Weekly Supp. 124a

Insurance — Personal injury protection — Claims — Timeliness — Where medical provider never submitted MRI bill to insurer, and bill was submitted by insured’s attorney five months after treatment was rendered, trial court correctly concluded that medical provider lost right to be paid for MRI — Med pay — Error to enter summary final judgment in favor of insurer where, in absence of statutory or contractual restriction, insured may be entitled to recover from med pay coverage the 20% of MRI bill that would have remained unpaid by PIP had claim been properly submitted

13 Fla. L. Weekly Supp. 176a

Insurance — Personal injury protection — Coverage — Medical provider — Unregistered clinic — Where medical provider was clinic required to register under section 456.0375 but was not registered, insurer is entitled to reimbursement from provider for all expenses paid by each insured’s PIP and med pay coverage for treatment rendered while provider was not registered

13 Fla. L. Weekly Supp. 151a

Insurance — Personal injury protection — Coverage — Medical provider — Unregistered clinic — Where medical provider was clinic required to register under section 456.0375 but was not registered, insurer is entitled to reimbursement from provider for all expenses paid by each insured’s PIP and med pay coverage for treatment rendered while provider was not registered