9 Fla. L. Weekly Supp. 414a
Insurance — Personal injury protection — Coverage — Medical expenses — Insurer is required to pay claim by insured for reasonable expenses of MRI billed by MRI provider which contracted with an imaging facility to provide the MRI — Where insured did not assign her PIP benefits to MRI provider and was a stranger to any business dealings between MRI provider and the imaging facility, defense of illegality or violation of public policy is unavailable to insurer — No merit to insurer’s assertion that it was not on notice of claim because MRI provider did not identify the imaging facility on the HCFA Form 1500 — Insurer’s indemnification of insured does not excuse its failure to timely pay claim in accordance with the law and policy
DIANA L. BARCUS, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 00-CC-2529-20-U. April 2, 2002. Donald L. Marblestone, Judge. Counsel: Steven L. Barcus, Altamonte Springs. Robert A. Kingsford, Orlando. Charles J. Kane, Boca Raton.
[Affirmed at 10 Fla. L. Weekly Supp. 790a.]Final Summary Judgment
On January 31, 2002, the Court heard Barcus’s motion for final summary judgment. The following facts are undisputed. Barcus was injured in a motor vehicle accident. Her treating physician issued a prescription and ordered an MRI from Medical Management Group of Orlando, Inc. (“MMGO”). She underwent the procedure on May 16, 2000 and executed a Direct Payment Authorization Without Assignment of Benefits permitting MMGO to submit a claim to State Farm. MMGO submitted the claim on HCFA Form 1500 identifying MMGO as the supplier of services without identifying the imaging facility and location where the testing actually occurred. MMGO has a business lease with an imaging company that possesses the necessary equipment and engages the necessary personnel to perform the testing entitling MMGO to use the equipment and personnel on a part-time basis. MMGO obtained written interpretation of the images from Richard J. Bagby, M.D. and submitted it with the claim form. State Farm received the submission on June 12, 2000. On July 19, 2000, State Farm’s Claim Specialist, Lydia Levasseur, wrote letters to Barcus and MMGO asserting State Farm was not on notice of the claim because MMGO did not complete Block 32 of the form, a space for identifying the imaging facility and its location. Levasseur opined “only the person or institution lawfully rendering MRI services to Diana Barcus may charge State Farm for those services.” State Farm’s policy requires payment of the debt Barcus incurred to her or, at State Farm’s option, to the renderer of service, within the 30 days prescribed by law. State Farm has not paid anyone for the testing and written interpretation Barcus received. Barcus filed suit asserting a claim for these unpaid benefits.
Levasseur was deposed. She admitted the testing and interpretation were medically necessary in connection with treatment of Barcus for injuries she sustained in a covered motor vehicle accident and that the claimed amount, $1250, was within the amount State Farm usually pays to facilities possessing the equipment. No assertion has been made that $1250 is not reasonable for the work done. Levasseur also made the following admissions in her testimony:
Q All right. So that when you say in the first sentence on page two of your letter of July the 19th, “Payment will be issued directly to the person or institution that lawfully rendered the services reflected in your Form 1500, assuming a valid assignment of benefits has been made,” aren’t you telling Medical Management Group, as of July the 19th, and based upon the documents you have you’re not going to pay them?
A Well, basically we would owe the payment to Diana Barcus, not to whomever provided the service. And usually I issue the payment directly to the provider instead of the insured, to assure that the provider got payment within a stipulated time by the PIP Statute.
Q So you agree, then, that without a doubt an MRI was done here and a payment was then due to Diana Barcus?
A That’s correct, even though there was not evidence that we really owed Medical Management Group of Orlando, the MRI services, we would have paid Medical Management Group of Orlando — I would have paid.
Q Did you ever issue payment to Diana Barcus with regard to this claim?
A No, never issued payment to Diana Barcus regarding the claim, because we didn’t have the information to be able to process the payment.
State Farm defends asserting MMGO’s business arrangement with the imaging facility is unlawful pursuant to F.S. §817.505. It also asserts only the imaging facility owning the magnet may charge Barcus, and that under the No-Fault law it is only obligated to indemnify Barcus when she directly incurs the obligation to that facility instead of indirectly through obligation to MMGO.
State Farm cites as authority Federated National Insurance Company v. Physicians Charter Services, 788 So.2d 403 (Fla. 3rd DCA 2001) and Medical Management Group of Orlando, Inc. v State Farm Mutual Automobile Insurance Company, 8 Fla. L. Weekly Supp. 361 (Fla. 9th Jud. Cir. 2001), a trial court decision currently on appeal to the Fifth District Court of Appeals. The Court finds these cases distinguishable from this case as both cases were filed by assignees.1 However, Barcus never assigned her benefits to MMGO and is a stranger to any business dealings between that company and third parties that State Farm asserts are illegal. The defense of illegality or violation of public policy obtains only where the party seeking relief is culpable in the transgression. State Farm has alleged no such transgression by Barcus. Levassuer’s admissions on behalf of State Farm establish a prima facie case for Barcus.
State Farm’s assertion it was not on notice is unfounded. Levasseur admits she understood the nature of the claim to be for MRI services and that the amount claimed was $1250. In addition, the law merely requires the claim be submitted “on” the prescribed form and is silent as what portions must necessarily be completed. F.S.§627.736(5)(b). This Court has no authority to establish regulations for the use of the form. Article 2 §3 of the Florida Constitution. The claim was submitted with a written interpretation identifying the radiologist. State Farm’s assertion it was entitled to request additional information it deemed pertinent is correct. But failure to make request within 20 days after the claim was received did not extend the time for paying the claim. F.S.§627.736(6). State Farm’s adjustors whose depositions are on file admit they have a duty to investigate all claims and to treat all claimants equally.2 The claim form submitted clearly put Levasseur on inquiry as she made inquiry in her letter of July 19, 2000. Payment of the claim was overdue before Levassuer made her request for additional information. F.S.§627.736(4)(b). The delay in inquiry does not excuse State Farm. Notice is imputed. Negligent ignorance has the same effect in law as actual knowledge, where there is a duty of finding out and knowing. Farish v. Smoot, 58 So.2d 534 (Fla. 1952); Redstone v. Redstone Lumber & Supply Co., 101 Fla. 226, 133 So. 882 (1931). The purpose of the PIP law is to “provide swift and virtually automatic payment so that the injured insured may get on with his life without undue financial interruption.” Ivey v. Allstate Ins. Co., 774 So.2d 679, 683 (Fla. 2000). Further investigation and delay of payment admittedly due Barcus did not serve that purpose. It only served to assist State Farm in seeking information about those it asserts do not “render” “treatment” as State Farm interprets those terms.
State Farm argued it gave Barcus its undertaking to indemnify her for any claim brought against her by MMGO and that this indemnification shows she has no damage or somehow excuses State Farm’s failure to pay. An insured may be damaged by an insurance company’s failure to pay a claim even though the insured has not paid or been sued by the medical provider. Kaklamanous v. Allstate Ins. Co., 796 So.2d 555, 561 (Fla. 1st DCA 2001). Such indemnification is not material as it does not excuse failure to timely pay in accordance with the law and the policy.
State Farm admitted $1250 is a reasonable amount. Any other argument asserting charges from MMGO are unreasonable are not material as the price is admitted to be reasonable.
State Farm adjustors whose depositions have been filed admit diagnostic testing is not “treatment” as it applies no modality to effect change in a patient’s condition. Coverage under subsection (1)(a) of the law extends to other services that are not necessarily “treatment”, such as Xray services and ambulance services. There is other statutory support for the notion that diagnostic testing is not treatment but is an “assist” in diagnosis and treatment. See F.S.§766.111.
There is no doubt or dispute that Barcus incurred a debt to MMGO and received exactly the necessary product and services her treating physician ordered. No showing or allegation has been made that Barcus has no liability for the necessary testing services and interpretation she received. Clearly she is entitled to no windfall. Similarly, neither is State Farm. State Farm has no standing to assert defenses only available, if at all, to Barcus.
This Court has no jurisdiction to regulate the use of the mandated billing form and has no jurisdiction to adjudicate some asserted unfiled criminal charge or asserted public policy violation not involving misconduct by Diana Barcus. Accordingly, summary final judgment is awarded to Diana Barcus against State Farm Mutual Automobile Insurance Company in the principal sum of $1250. Jurisdiction is reserved to award prejudgment interest, costs and reasonable attorneys fees.Certification of Ouestion of Great Public Importance
The Court hereby certifies the following question as a question of great public importance:
IS A FLORIDA NO-FAULT INSURANCE POLICY REQUIRED TO PROVIDE COVERAGE TO AN INSURED FOR THE REASONABLE EXPENSE INCURRED IN CONTRACTING WITH A PROVIDER OF MRI SERVICES THAT MADE BUSINESS ARRANGEMENTS TO CAUSE TO BE DELIVERED TO THE INSURED COVERED PRODUCTS AND SERVICES WHERE THE INSURED VIOLATED NO LAW OR PUBLIC POLICY AND WHERE THERE IS NO CONTRACTUAL RELATIONSHIP BETWEEN THE INSURER AND THE MIDDLEMAN?
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1Barcus filed the trial court opinion of Judge Young in Federated revealing Physician’s Charter Services had standing as assignee of Federated’s covered insured. That was also evident form the style of the case as a corporation only has standing in a PIP case where it is an assignee of the insured. Nationwide Mut. Fire Ins. Co. v. Pinnacle Medical, Inc., 753 So.2d 55 (Fla. 2000); Parkway General Hospital, Inc. v. Allstate Ins. Co., 393 So.2d 1171 (Fla. 3rd DCA 1981).
2See also F.S.§626.878; Fla. Admin. Code Ch. 4-220.201(4).
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