In United Automobile Insurance Company v. Santa Fe Medical Center, ____ So.3d ____ (Fla. 3d DCA October 7, 2009), the medical provider took an assignment of PIP benefits from its patient. Santa Fe submitted bills to United Auto for treatment rendered, and United Auto denied payment claiming that the treatment was not reasonable, necessary or related to the subject accident.
United Auto did not obtain a written report from a physician prior to denying the claim. Much later, in response to Santa Fe’s motion for summary judgment, United Auto did obtain an affidavit from a physician supporting its denial of the claim. The trial court rejected United Auto’s affidavit because: (1) it was based upon his review of the patient’s treatment records, rather than a physical examination of Mr. Lopez, and (2) United Auto’s physician did not conduct his review or submit his affidavit within thirty days of United Auto’s receipt of the claim. United Auto appealed to the Circuit Court which affirmed the trial court on these two issues. United Auto sought certiorari review from the 3rd DCA.
The 3rd DCA reversed. The Court noted a clear distinction between the denial of a past bill which is controlled by subsection (4)(b) of the PIP statute; and the withdrawal of future benefits which is controlled by subsection (7)(a). According to the 3rd,
[b]ecause this is a denial case, subsection (4)(b) applies. Subsection (4)(b) provides that the insurer must pay benefits that are reasonable, related, and necessary within thirty days after receiving written notice, and the failure to do so could subject the insurer to penalties. However, if the insurer believes that the claim is not reasonable, related, and necessary and denies the claim, it may obtain and offer reasonable proof at any time to establish that the insurer is not responsible for payment of the claim…. ‘Reasonable proof’ is not defined, but it is clear that subsection (4)(b) does not require that a ‘valid report‘ be obtained to protect an insurer from being assessed statutory penalties when denying a claim. It is important to note that the statute does not require the insurer to obtain a report or proof under subsection (4)(b) before denying a claim.
In conclusion, the Court stated:
If the insurer believes the claim is not reasonable, related, and necessary, it may: (1) deny the claim; or (2) pay the claim until it obtains a valid medical report under subsection (7)(a) and withdraw further payment. ‘Reasonable proof’ when defending an insurer’s decision to deny payment of a claim under subsection (4)(b) does not require that the insurer obtain a valid report pursuant to subsection (7)(a), and the insurer may contest its responsibility to pay a claim at any time, and present evidence obtained after the thirty-day period has expired. Subsection (7)(a), which requires that the insurer obtain a valid medical report, only applies to instances where the insurer withdraws the payment of further PIP benefits, not to the denial or reduction of benefits claimed.
Be aware, that in its opinion, the Court also noted that in withdrawal cases under subsection (7)(a), that an insurer’s "valid report" "may be based on the reporting physician’s review of another physician’s examination," or the reviewing physicians own physical examination.