Volume 7

7 Fla. L. Weekly Supp. 745b

Insurance — Personal injury protection — HCFA form submitted by medical provider which contained insured’s name, address and telephone number; claim number assigned by insurer; fact that claim was related to automobile accident; nature of service provided by medical provider, and bill for provider’s service was sufficient to serve as written notice of a covered loss and amount of loss — Upon receipt of HCFA form, burden was on insurer to authenticate claim within thirty days; if insurer could not prove it was not responsible for payment, it should have paid claim within thirty days of date of receipt of HCFA form — Because insurer failed to obtain any proof it was not responsible, plaintiff is now entitled to statutory interest and attorney’s fees and costs — Argument that written notice of covered loss did not occur until receipt of no-fault application is not supported by case law or reasonable interpretation of statute

7 Fla. L. Weekly Supp. 626a

Insurance — Personal injury protection — Where decedent was covered by policy of automobile insurance which included $10,000 in no-fault coverage, with $2,000 deductible, insurer appropriately paid to estate $5,000 death benefit, and then $3,000 balance of available coverage as against hospital/medical expenses — Argument that statutory $5,000 death benefit is separate and distinct from mandated $10,000 in coverage rejected — Neither a creative application of deductible, nor any rule of law arguably requiring a liberal interpretation of No-Fault Act, can mandate a result of more than $3,000 in benefits being payable once death benefit is paid

7 Fla. L. Weekly Supp. 661a

Insurance — Personal injury protection — Insurer is not required to obtain written report of physician licensed under same chapter as insured’s medical provider before paying amount less than that billed by medical provider on ground that charges exceeded usual and customary charges — Section 627.736(5), rather than sections 627.736(1)(a) or 627.736(7), applies where insured’s medical condition is not at issue — Court recedes from its prior ruling in Progressive Speciality Insurance Company v. Biomedical Trauma Association, Inc., to extent it conflicts with ruling in instant case

7 Fla. L. Weekly Supp. 620b

Insurance — Personal injury protection — Insurer, who seeks to reduce amount paid for medical treatment based upon unreasonableness of charge, need not obtain a report from physician licensed under same chapter as treating physician stating that treatment was not reasonable, related or necessary, before paying claim at amount less than amount billed — Where medical providers were paid substantial portion of claims in timely fashion and only a portion of bill was denied because it was determined that charges exceeded reasonable and customary charges for particular geographic region, report is not required

7 Fla. L. Weekly Supp. 591a

Insurance — Personal injury protection — Before insurer reduces medical charges and/or defends lawsuit for benefits, insurer must obtain report from physician stating that charges are excessive — Requirement that report be obtained applies to any nonpayment of medical benefit due to finding that services were not reasonable, related, or necessary, including a reduction of benefits based upon finding that medical charges were in excess of usual and customary rates

7 Fla. L. Weekly Supp. 546b

Insurance — Personal injury protection — In claim for PIP benefits in which insurance carrier has withdrawn, reduced or denied further benefits, it is condition precedent under section 627.736(7)(a) that insurer obtain report by a physician licensed under the same chapter as the treating physician stating that the treatment was not reasonable, related, or necessary in order for an insurance carrier to defend a suit for reduction, withdrawal or denial of further payments on grounds of reasonableness, necessity, or relationship — Court’s ruling applies to “usual and customary” reductions — Explanation of Benefits will not substitute for medical report required by statute

7 Fla. L. Weekly Supp. 807a

Insurance — Personal injury protection — Insurer, who refused to pay total amounts contained in bills submitted by healthcare providers and only paid what it deemed to be reasonable charges for medically necessary services, is entitled to summary judgment on claim seeking payment of PIP benefits as there is complete absence of any material issues of fact — Insurer does not breach its insurance contract by refusing to pay for all, as opposed to only reasonable health care services provided to insured — Insured is removed from jeopardy and cannot suffer damages as matter of law where enforceable contractual obligation upon insurer is created by correspondences from insurer to insured agreeing to defend and indemnify insured in event any cause of action is brought by healthcare provider against insured for outstanding bills

7 Fla. L. Weekly Supp. 687a

Insurance — Personal injury protection — Insurer does not breach insurance contract with the insured by refusing to pay for all, as opposed to only the reasonable, health care services provided to insured — Correspondences from insurer to insured, agreeing to defend and indemnify insured if any cause of action is brought by healthcare provider against insured for outstanding bills, creates enforceable contractual obligation — As such, insured is removed from jeopardy and cannot suffer damages as matter of law

7 Fla. L. Weekly Supp. 546a

Insurance — Personal injury protection — Motion for summary judgment granted as plaintiff has no cause of action for breach of contract when insurer contends that it has paid all reasonable expenses submitted and has promised to defend and indemnify plaintiff should plaintiff be pursued by any health care provider for balance resulting from insurer’s determination that amount of submitted charge was unreasonable — Attorney’s fees — Motion for partial summary judgment and to determine entitlement to attorney’s fees denied except as to interest issues — A report, as described in Section 627.736(7), Florida Statutes, is not required before insurer can defend based upon contention that amount of charges at issue is unreasonable — Issues surrounding reasonableness of amount of charges are governed by Section 627.736(5), Florida Statutes, which contains no similar “report requirement”

7 Fla. L. Weekly Supp. 803a

Insurance — Personal injury protection — In accordance with denial of insurer’s motion for summary judgment based on non-compliance with Section 627.736(5)(b), grant of plaintiffs’ summary judgment motion, and court’s holding that Section 627.736(5)(b) is unconstitutional as violative of plaintiffs’ rights of due process, equal protection, and access to courts, insurer shall pay to insured and healthcare provider amount of billed charges for medical treatment rendered for injuries insured sustained in motor vehicle accident, interest, and reasonable attorney’s fees

Reversed and remanded at 27 Fla. L. Weekly D321a
District Court opinion approved at 30 Fla. L. Weekly S197b