In Central Magnetic Imaging Open MRI of Plantation, Ltd a/a/o v. State Farm Fire and Casualty Insurance Company, ____ So.3d ____ (Fla. 4th DCA November 18, 2009), State Farm received an MRI bill on one of its PIP insureds. State Farm sent the MRI bill and its PIP insured’s medical records to be reviewed by its own physician to determine if the MRI was reasonable, necessary and related to a motor vehicle accident. State Farm did not have its PIP insured physically examined by its physician.
Based on the report for the reviewing physician, State Farm denied payment for the bill. The MRI facility, as assignee of the insured, filed suit against State Farm for breach of the insurance contract. On summary judgment in the county court, the MRI facility argued that State Farm was required by 627.736(7)(a) to obtain a "valid report" prior to denying the MRI bill. The MRI facility argued that an essential element of a "valid report" was that State Farm had to obtain a physical exam of its insured prior to denying the bill. The county court agreed, but the circuit court reversed finding that no physical examination was necessary.
The 4th DCA denied the petition for certiorari, finding that the circuit court applied the correct law. According to the 4th
We conclude, in line with the Third District Court of Appeal, that the ‘valid report’ required by the statute does not require an insurer to order an IME before denying a claim for PIP benefits.
In a footnote, the 4th did note that
Although the issue was not raised in this case, we note that other districts have held that the valid report requirement of section 627.736(7)(a) does not apply at all in a case such as this…. [However, in this case, t]he insurer conceded that the valid report requirements applied to the claim in this case.
As previously noted in this blog, numerous cases have held that 627.736(7)(a) only applies to the withdrawal of future benefits, and section (4)(b) applies to the denial of a past bill. Section (4)(b) does not require a report at all. Section (4)(b) merely requires an insurer to provide "reasonable proof" that the bill is not owed, and such "reasonable proof" can be produced at any time.