18 Fla. L. Weekly Supp. 868a
Online Reference: FLWSUPP 1809CHIR
Insurance — Personal injury protection — Declaratory judgment — Where medical provider made false and misleading statements in claims for PIP benefits, insurer does not owe provider PIP or Medpay benefits for claims, and insured does not owe provider compensation for services
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY and STATE FARM FIRE AND CASUALTY COMPANY, Plaintiffs, v. CHIROPRACTIC ONE, INC., Defendant. Circuit Court, 9th Judicial Circuit in and for Orange County. Case No. 05-CA-5847, Div. 37. January 19, 2011. Robert M. Evans, Judge. Counsel: Kenneth P. Hazouri, deBeaubien, Knight, Simmons, Mantzaris & Neal, LLP, Orlando, for Plaintiffs. Sylvia A. Grunor, Weiss, Grunor, Weiss, Maitland, for Defendant.FINAL SUMMARY JUDGMENT
THIS MATTER came before the Court on December 15, 2010, on the Motion for Final Summary Judgment of Plaintiffs, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY and STATE FARM FIRE AND CASUALTY COMPANY (collectively “State Farm”), and the Court having reviewed the Motion, the evidence submitted both in favor of, and in opposition to, the Motion and the court file, having heard the oral argument of counsel, and being otherwise fully advised in the premises, hereby makes the following findings and conclusions of law:
1. The Court hereby readopts and incorporates herein by reference all of the findings, analysis, and rulings set forth in the February 10, 2009, Order Granting State Farm’s Motion for Partial Summary Judgment herein, a copy of which is attached hereto as Exhibit “A.” [16 Fla. L. Weekly Supp. 315a].
2. The Court hereby readopts and incorporates herein by reference all of the findings, analysis, and rulings set forth in the June 1, 2010, Order Granting State Farm’s Motion for Summary Judgment on Defendant’s Claims for Treatment of Carmen Baez, Gerard Malone, Holly Minge, and Irma Howell herein, a copy of which is attached hereto as Exhibit “B.”
3. State Farm’s Motion for Final Summary Judgment (the “Motion”) requests this Court to enter a final summary judgment declaring that Defendant, CHIROPRACTIC ONE, INC. (“Chiro One”), is not entitled to recover any personal injury protection (“PIP”) or medical payments (“MP”) benefits for any of the treatment provided by Chiro One to the following State Farm insureds: Stephen Bilsky, Tammy Clark, Lauren Colon, Stephanie Colon, Jessica George, Ettaleen Griffin, Emerson Henao, Tracy Oskerson, Alicia Paschek, Michelle Pender, Mitzy Rivas, Cyntra Seegulam, Gwendolyn Thomas, Sally Watson, and Ronda Wilson (sometimes collectively referred to as the “Insureds”). The Court previously made that same adjudication and declaration on Chiro One’s claims for treatment of State Farm insureds, Carmen Baez, Gerard Malone, Holly Minge, and Irma Howell in the June 1, 2010, Order attached hereto as Exhibit “B.”
4. Together with all of the other record evidence in this action, the Affidavits of William W. Talley filed in support of this Motion, and the chiropractic and billing records attached thereto, establish beyond any material issue of fact that: a) Chiro One repeatedly made the same types of false and misleading statements as those documented in this Court’s February 10, 2009, Order within Chiro One’s claims for PIP benefits for treatment of the Insureds; b) each of Chiro One’s claims for PIP benefits for treatment of the remaining Insureds contains at least one such false and misleading statement, and the claims usually contain multiple and repeated instances of such statements.
5. Without limitation, the same evidence establishing that Chiro One “knowingly” made the false and misleading statements within Chiro One’s claims for PIP benefits for its treatment of Carmen Baez, Gerard Malone, Holly Minge, and Irma Howell, as set forth in this Court’s June 1, 2010, Order, also establishes beyond any material issue of fact that Chiro One “knowingly” made the false and misleading statements within Chiro One’s claims for PIP benefits for treatment of the remaining Insureds at issue in State Farm’s Motion.
6. Pursuant to section 627.736(5)(b)(1)(c), Florida Statutes, State Farm does not owe Chiro One any PIP benefits for any of Chiro One’s treatment of the Insureds. Likewise, the Insureds do not owe Chiro One any compensation for any of the services included in Chiro One’s claims for treatment of them pursuant to section 627.736(5)(b)(1)(c), Florida Statutes.
7. Since State Farm does not owe any PIP benefits on such claims, State Farm likewise does not owe Chiro One any MP benefits for any of the treatment. State Farm Mutual Automobile Ins. Co. v. Pressley, 28 So.2d 105, 109, n. 3 (Fla. 1st DCA 2010) [35 Fla. L. Weekly D150b].
Based on the foregoing findings and conclusions of law, it is hereby ORDERED and ADJUDGED:
1. Plaintiffs’ Motion for Final Summary Judgment is GRANTED.
2. The Court declares that State Farm does not owe any PIP and MP benefits for any of the charges encompassed within Defendant, CHIROPRACTIC ONE, INC.’s, claims for treatment of Stephen Bilsky, Tammy Clark, Lauren Colon, Stephanie Colon, Jessica George, Ettaleen Griffin, Emerson Henao, Tracy Oskerson, Alicia Paschek, Michelle Pender, Mitzy Rivas, Cyntra Seegulam, Gwendolyn Thomas, Sally Watson, and Ronda Wilson.
3. Having declared that State Farm does not owe Defendant CHIROPRACTIC ONE, INC., any PIP or MP benefits for its treatment of any of the insureds/patients at issue herein, this declaratory action is now fully adjudicated, and the judicial labor on its merits is complete.
4. The Court reserves jurisdiction to award State Farm the costs it has incurred in the prosecution of this action.
__________________
ORDER GRANTING PLAINTIFFS’ MOTION FOR SUMMARY JUDGMENT ON DEFENDANT’S CLAIMS FOR TREATMENT OF CARMEN BAEZ,HOLLY MINGE, GERARD MALONE,AND IRMA HOWELL
THIS MATTER came before the Court on May 10, 2010, on the above-referenced Motion of Plaintiffs, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY and STATE FARM FIRE AND CASUALTY COMPANY (collectively “State Farm”), and the Court having reviewed the Motion, the evidence submitted both in favor of and in opposition to the Motion, and the court file, having heard the oral argument of counsel, and being otherwise fully advised in the premises, hereby makes the following findings and conclusions of law:
1. The Court hereby readopts and incorporates herein by reference all of the findings and rulings set forth in the February 10, 2009, Order Granting State Farm’s Motion for Partial Summary Judgment (the “Order”) herein, a copy of which is attached hereto as Exhibit “A.”
2. State Farm’s Motion for Summary Judgment on Defendant’s Claims for Treatment of Carmen Baez, Holly Minge, Gerard Malone, and Irma Howell (the “Motion”) requests this Court to enter a summary judgment declaring that Defendant, CHIROPRACTIC ONE, INC. (“Chiro One”), is not entitled to recover personal injury protection (“PIP”) or medical payments (“MP”) benefits for any of the treatment provided by Chiro One to four patients/insureds: Gerard Malone, Carmen Baez, Holly Minge, and Irma Howell (sometimes collectively referred to as the “Insureds”).
3. State Farm requests this relief pursuant to section 627.736(5)(b)(1)(c), Florida Statutes (“§ 627.736(5)(b)(1)(c)”), which reads in relevant part as follows:
(b)1. An insurer or insured is not required to pay a claim or charges:
* * *
c. To any person who knowingly submits a false or misleading statement relating to the claim or charges; (emphasis supplied)
4. A plain reading of § 627.736(5)(b)(l)(c) establishes that if a medical provider “knowingly submits a false and misleading statement relating” to any charge within, or portion of, the provider’s entire claim for all of its treatment of a patient/insured, then the insurer is not required to pay PIP benefits to the medical provider for any of the charges encompassed within the entire claim. In the context of insurance, the term “claim” is commonly understood to mean an assertion of a right to payment of benefits under an insurance policy, which may include different charges, elements, or damages that make up the entire “claim.” As used in § 627.736(5)(b)(l)(c), therefore, the term “claim” means the medical provider’s entire “claim” for all of the treatment provided to a patient/insured, which “claim” will normally include itemized “charges” for specific services provided to the patient/insured throughout the course of treatment.
Moreover, § 627.736(5)(b)(1)(c) states that a PIP insurer “is not required to pay a claim . . . to any person who knowingly submits a false and misleading statement relating to the claim or charges.” (emphasis supplied) Accordingly, once the “person” (in this case Chiro One) knowingly makes a false or misleading statement relating to the claim or charges, that “person” shall not be paid any PIP benefits for any portion of the “person’s” entire “claim” for treatment of the patient/insured. if, therefore, a medical provider makes a false or misleading statement relating to one portion of its entire claim for treatment provided to a patient/insured, the medical provider loses the right to recover PIP benefits for any and all portions of the entire claim, and all charges encompassed therein, pursuant to § 627.736(5)(b)(1)(c).
5. In addition to the plain language of § 627.736(5)(b)(1)(c), this conclusion is consistent with the Legislature’s intent, which is to: a) encourage insurers to take a stronger stance against paying fraudulent or otherwise improper claims for PIP benefits; and b) provide insurers with sufficient tools to do so. See, e.g., Regional MRI of Orlando, Inc. v. Nationwide Fire Ins. Co., 884 So.2d 1102 (Fla. 5th DCA 2004) [29 Fla. L. Weekly D2355b](quoting the Legislature’s findings, in support of its amendments to § 627.736, that “fraud, medically inappropriate over-utilization of treatments and diagnostic services, inflated charges, and other practices” are significantly impairing the beneficial purpose of the PIP statute).
Conversely, allowing a medical provider to recover some of its charges after making false and misleading statements regarding the provider’s claim to an insurer does not deter fraudulent or otherwise improper billing and treatment practices. Instead, such a result encourages an unscrupulous medical provider to bill for fraudulent or otherwise improper charges, in addition to any legitimate ones, because the provider knows the worst that can happen is the insurer’s denial of payment for the fraudulent and/or improper charges, on which the provider had no right to be paid, and should not have even not billed, in the first place. In other words, there would be no downside risk to billing fraudulent or otherwise improper charges, which would incentivize unscrupulous medical providers to do so. Such a result is wholly inconsistent with the policy and purpose of § 627.736(5)(b)(1)(c).
6. Section 627.732(10), Florida Statutes (“§ 627.732(10)”), defines the term “knowingly,” as used in § 627.736(5)(b)(1)(c), as follows:
“Knowingly” means that a person, with respect to information, has actual knowledge of the information; acts in deliberate ignorance of the truth or falsity of the information; or acts in reckless disregard of the information, and proof of specific intent to defraud is not required.
7. As more specifically set forth in the February 10, 2009, Order attached hereto, the Court has already found that Chiro One made false and misleading statements relating to, and within, the claims of each of the Insureds at issue in State Farm’s Motion. Accordingly, the issue for resolution in the instant Motion is whether or not Chiro One “knowingly” made such false and misleading statements as defined in § 627.732(10), such that State Farm and the Insureds are relieved from paying Chiro One for any of the services billed within Chiro One’s claims for treatment of the Insureds pursuant to § 627.736(5)(b)(1)(c).
8. State Farm’s Motion sets forth substantial, competent evidence, including the deposition testimony of Chiro One’s owner, Dr. Richard Bocco, clearly establishing that Chiro One “knowingly” (as defined in § 627.732(10)) made the false and misleading statements identified in the Court’s February 10, 2009, Order. On the other hand, Chiro One has not filed any contradictory evidence sufficient to create a material issue of fact on this element of § 627.736(5)(b)(1)(c).
9. Based on the foregoing, the Court finds that Chiro One “knowingly” made the false and misleading statements set forth in the Court’s February 10, 2009, Order. Pursuant to § 627.736(5)(b)(1)(c), therefore, State Farm does not owe Chiro One any PIP benefits for any of the services included in Chiro One’s claims for treatment of the Insureds. Likewise, the Insureds do not owe Chiro One any compensation for any of the services included in Chiro One’s claims for treatment of them pursuant to § 627.736(5)(b)(1)(c).
10. Since State Farm does not owe PIP benefits for any of Chiro One’s treatment of the Insureds, State Farm likewise does not owe any MP benefits for any of the treatment. State Farm Mutual Automobile Ins. Co. v. Pressley, 28 So.2d 105, 109, n. 3 (Fla. 1st DCA 2010).
Based on the foregoing findings and conclusions of law, it is hereby ORDERED and ADJUDGED:
1. Plaintiffs’ Motion for Summary Judgment on Defendant’s Claims for Treatment of Carmen Baez, Holly Minge, Gerard Malone, and Irma Howell is GRANTED.
2. Pursuant to § 627.736(5)(b)(1)(c), the Court hereby declares that State Farm does not owe any PIP and MP benefits for any of the charges encompassed within Defendant, CHIROPRACTIC ONE, INC.’s, claims for treatment of Carmen Baez, Holly Minge, Gerard Malone, and, Irma Howell.