Volume 18

18 Fla. L. Weekly Supp. 575a

Online Reference: FLWSUPP 1807DOLZ Insurance — Personal injury protection — Examination under oath — Failure to answer questions — Trial court properly denied insurer’s motion for summary judgment on issue of whether insured unreasonably refused to submit to EUO and sent issue to jury where insured did attend EUO and refused to answer certain questions on advice of counsel — Attendance at EUO is not condition precedent to filing suit for PIP benefits or recovery of benefits — To extent that policy provisions requiring attendance at EUOs are valid, EUO is condition subsequent that requires showing of prejudice on part of insurer

18 Fla. L. Weekly Supp. 335a

Online Reference: FLWSUPP 1804DESA Insurance — Personal injury protection — Coverage — Notice of loss — Where medical provider was informed that patient did not have vehicle or insurance but might have coverage under mother’s PIP policy, and provider filed claim within 35 days of receipt of correct name and address of mother’s insurer, bills were payable — Error to impose on provider requirement to investigate patient’s insurance — Requirement that provider submit denial letter from incorrect insurer or proof of mailing showing timely mailing to incorrect insurer applies only when patient provides incorrect insurance information, not when patient mistakenly claims to have no coverage

18 Fla. L. Weekly Supp. 558a

Online Reference: FLWSUPP 1806GGAR

Insurance — Personal injury protection — Notice of loss — Claim form — Professional license number — Where insurer’s only basis for denying claim was failure of MRI provider to provide professional license number on claim form and case was stayed pending outcome of appellate case in which court held that MRI provider is not required to supply professional license number on claim form, retroactive application of appellate decision results in finding that insurer had no reasonable proof that it was not responsible for claim and is, therefore, liable for claim despite intervening exhaustion of all but $14 in benefits

18 Fla. L. Weekly Supp. 140a

Online Reference: FLWSUPP 1802TARP Insurance — Personal injury protection — Notice of loss — HCFA form — Professional license number — Error to enter summary judgment in favor of insurer based on medical provider’s failure to provide notice of covered loss due to omission of provider’s professional license number from original claim forms — On remand, trial court must determine whether original forms were substantially complete and whether any material error or omission on original forms was sufficiently cured by provider’s submission of amended claim forms

18 Fla. L. Weekly Supp. 400a

Online Reference: FLWSUPP 1804BUSO Insurance — Personal injury protection — Coverage — Medical expenses — Testimony of litigation adjuster is not sufficient to preclude summary judgment on issue of reasonableness, relatedness and necessity of services — CPT coding — Trial court refuses to consider affidavit opining that medical provider improperly coded services where affidavit is contrary to insurer’s explanation of benefits, pleadings and sworn testimony regarding basis for denial of codes — Further, insurer waived affirmative defenses of upcoding or unbundling by failing to plead them — Version of PIP statute in effect at time policy was executed, which provides for payment of 80% of reasonable medical expenses, rather than version in effect at time of accident, which provides for payment of 200% of Medicare or workers’ compensation fee schedule, is applicable where statutory change affects substantive rights and insurer failed to follow policy requirements to amend policy to allow payment pursuant to 2008 PIP statute

18 Fla. L. Weekly Supp. 399b

Online Reference: FLWSUPP 1804MURR

Insurance — Personal injury protection — Lost wages — Insurer breached PIP policy and violated PIP statute by failing to reserve PIP benefits for payment of lost wages as requested by insured

18 Fla. L. Weekly Supp. 314b

Online Reference: FLWSUPP 1803BROW Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Partial summary judgment is granted in favor of medical provider on improper coding defense where provider’s expert opined that billing met coding requirements of codebook that is one of treatises for determining coding compliance specified in PIP statute and insurer’s coding expert based opinion that claim was properly denied on “CPT Expert” which is not among specified treatises

18 Fla. L. Weekly Supp. 336b

Online Reference: FLWSUPP 1804APPL Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Evidence — Error to exclude affidavits of insurer’s non-physician expert regarding correctness of CPT code on claim forms — PIP statute does not require that insurer refute medical provider’s CPT code determination with physician’s affidavit — However, summary judgments in favor of provider are affirmed, as opposing affidavits asserting that provider’s documentation is deficient but offering nothing to attack claim that provider performed CPT code create no material issue of disputed fact

18 Fla. L. Weekly Supp. 547a

Online Reference: FLWSUPP 1806CHRI Insurance — Personal injury protection — Coverage — CPT coding — Insurer correctly denied payment for inappropriately unbundled services — National Correct Coding Initiative edits are payment limitations, not utilization limitations that would be prohibited under PIP statute

18 Fla. L. Weekly Supp. 1050a

Online Reference: FLWSUPP 1810BONH Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Unbundling — Medical provider inappropriately unbundled and billed separately for re-reading of diagnostic scans performed as part of medical decision making and counseling components of evaluation and management CPT code which was billed for same day of service