13 Fla. L. Weekly Supp. 1019a
Insurance — Personal injury protection — Explanation of benefits — Medical provider/assignee was entitled to EOB even where EOB had been furnished to insured, and insurer had informed insured that it would not honor further bills for treatment rendered by provider in light of independent medical examination findings
R.J. TRAPANA, M.D., P.A., (a/a/o Paolo D’Onofrio), Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-01261 COSO 60. August 3, 2006. Sharon L. Zeller, Judge. Counsel: Joshua Meadow and Russel Lazega, Law Office of Russel Lazega, North Miami, for Plaintiff. Leonard Jackson, for Defendant.
ORDER ON PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT AS TO COUNT I OF PLAINTIFF’S COMPLAINT
This action came before the Court on Plaintiff’s Motion For Summary Judgment as to Count I of Plaintiff’s Complaint, and the Court having heard argument of counsel, and being otherwise advised in the premises, it is hereupon ordered and adjudged as follows:
Factual Findings
1. Patient was treated by the Plaintiff (claimant for all intents and purposes) on May 21, 2004 for injuries sustained in an accident on December 1, 2003.
2. Plaintiff submitted a perfected claim on or about May 24, 2004 to Defendant.
3. Defendant did not provide an itemized specification of charges it reduced or rejected to the Plaintiff as required by FS § 627.736(4)(b) (commonly referred to as an “explanation of benefits”).
4. Plaintiff sent a pre-suit demand letter to the Defendant pursuant to FS § 627.736(11) on July 26, 2004 specifically requesting an “explanation of benefits”.
5. Defendant failed to furnish the Plaintiff with an itemized specification/explanation of benefits in compliance with FS § 627.736(4)(b) due to the fact that it provided a letter to the insured informing him of United’s decision not to honor further bills for treatment rendered by an MD in light of the independent medical examination findings by a DC (chiropractor).
6. Defendant did not provide an itemized specification/explanation of benefits to the Plaintiff in response to the Demand Letter or make any response at all.
Conclusions of Law
Quite simply, an assignee medical provider is entitled to an itemized specification/explanation of benefits as to that provider’s services, even if one has been furnished to the insured, as the provider, by virtue of its assignment, has a stake in the claim and the same right as to the insured to the information.
This Court finds guidance in Judge Richard Eade’s decision in United Automobile Insurance Company vs. R.J. Trapana, M.D., P.A. (a/a/o Dudley Mabout), Circuit Court, 17th Judicial Circuit (Appellate) in and for Broward County, Case No. 03-222360 CACE 05 (February 14, 2005) reported at 12 Fla. L. Weekly Supp. 452a, where, as in this case, the Plaintiff brought an action for breach of contract where the insurer failed to provide an itemized specification pursuant to FS §627.736(4)(b) in response to a pre-suit demand for same. Judge Eade ruled “United Automobile’s failure to provide the required specification resulted in a breach of its obligation, entitling Trapana to attorney’s fees and costs.”
Accordingly, Partial Summary Judgment is entered for the Plaintiff, and Plaintiff is entitled to fees and costs pursuant to FS §627.428 to be determined at a later date.
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