Third District Court of Appeal
State of Florida
Opinion filed October 14, 2015.
Not final until disposition of timely filed motion for rehearing.
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No. 3D14-2290
Lower Tribunal No. 10-47390
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State Farm Mutual Automobile Insurance Company,
Appellant,
vs.
Isabel Gonzalez,
Appellee.
An Appeal from the Circuit Court for Miami-Dade County, Lourdes Simon,
Judge.
deBeaubien, Knight, Simmons, Mantzaris & Neal, LLP, and Kenneth P.
Hazouri (Orlando), for appellant.
Schwartz & Kirschbaum, and Michael J. Schwartz, for appellee.
Before ROTHENBERG, LAGOA, and SCALES, JJ.
ROTHENBERG, J.
State Farm Mutual Automobile Insurance Company (“State Farm”) appeals
from a final judgment awarding its insured, Isabel Gonzalez (“Gonzalez”), $685 in
personal injury protection (“PIP”) and medical payment (“Med-Pay”) benefits for
emergency treatment rendered at Mariners Hospital. Because the record reflects
that Gonzalez failed to comply with the notice requirements of section
627.736(5)(d), Florida Statutes (2000), State Farm did not owe PIP or Med-Pay
benefits to Gonzalez for her treatment at Mariners Hospital. Accordingly, we
reverse and remand for entry of a final judgment in favor of State Farm.
On May 27, 2001, when Gonzalez was hit by a vehicle, she was transported
to and received treatment at Mariners Hospital’s emergency room. Mariners
Hospital billed Gonzalez’s health insurer, CarePlus, $685 for the services, but did
not bill State Farm. CarePlus paid the bill.
On January 15, 2002, Gonzalez’s counsel sent a letter of representation to
State Farm, stating that Gonzalez was injured in the accident, requesting that State
Farm provide insurance information as required by statute, and attaching the police
report of the accident that indicated Gonzalez was transported to Mariners
Hospital. This letter, however, did not include a bill or a statement of Mariners
Hospital’s charges, nor demand payment of specific medical services provided to
Gonzalez.
After receiving the letter of representation, State Farm sent numerous letters
and made several calls to Gonzalez’s counsel requesting that counsel provide
information as to any treatment received by Gonzalez as a result of the accident
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and submit any bills and/or statements for any such medical treatment. Gonzalez’s
counsel failed to respond, and after State Farm did not receive any information
from Gonzalez’s counsel for nearly two years, State Farm closed its claim in
August 2004.
After Gonzalez’s repeated failure to provide State Farm with the requested
information regarding her medical treatment and nearly five years after the
accident, on May 26, 2006, Gonzalez filed an action against State Farm seeking to
collect uninsured motorist (“UM”) benefits. State Farm and Gonzalez settled the
UM action for $80,000. Less than a month after settling the UM action,
Gonzalez’s counsel demanded that State Farm pay an additional $10,000 in PIP
and $10,000 in Med-Pay benefits for services rendered by three medical
providers—Mariners Hospital ($685), Miami Neuro Center ($31,103), and
American Orthopedic ($350). When State Farm did not pay Gonzalez’s demands,
Gonzalez filed suit against State Farm seeking allegedly overdue and unpaid PIP
benefits under section 627.736, Florida Statutes (2000), and Med-Pay benefits
under the State Farm policy. During the litigation, Gonzalez was forced to
abandon her claim as to American Orthopedic when it was learned that those
services were rendered prior to the date of the accident. Just prior to the entry of
the final judgment, Gonzalez abandoned her claim for $31,103 as to Miami Neuro
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Center after State Farm learned that the lien for those services had been reduced to
$1000.
Thereafter, State Farm moved for summary judgment, asserting in part that
it did not owe PIP and Med-Pay benefits for Mariners Hospital’s charges because
State Farm did not receive a statement of charges as required under section
627.736(5)(d). The trial court denied State Farm’s motion for summary judgment,
and because State Farm did not challenge the reasonableness, relatedness, and
necessity of Mariners Hospital’s charges, the trial court entered a final judgment
awarding Gonzalez $685 in PIP and Med-Pay benefits for the treatment rendered at
Mariners Hospital. State Farm’s appeal followed.
State Farm contends that the trial court erred by denying its motion for
summary judgment because State Farm was never provided with a statement of
Mariners Hospital’s charges in compliance with section 627.736(5)(d), and
therefore, State Farm was not furnished with the requisite notice of the PIP claim.
State Farm argued that because it did not receive notice, the PIP benefits and the
Med-Pay benefits never became due. We agree.
An appellate court reviews a trial court’s ruling on a motion for summary
judgment de novo. Volusia Cnty. v. Aberdeen at Ormond Beach, L.P., 760 So. 2d
126, 130 (Fla. 2000); State Farm Mut. Auto. Ins. Co. v. Pressley, 28 So. 3d 105,
107 (Fla. 1st DCA 2010). “Summary judgment is proper when there is no genuine
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issue of material fact and the moving party is entitled to judgment as a matter of
law.” Pressley, 28 So. 3d at 107.
In the instant case, it is undisputed that the statement State Farm received for
Mariners Hospital’s medical services did not comply with section 627.736(5)(d).
Specifically, the statement was not submitted on one of the required forms and did
not identify each medical procedure by the Physicians’ Current Procedural
Terminology. Section 627.736(5)(d) specifically provides that “[a]ll statements
and bills for medical services rendered by any . . . hospital . . . shall be submitted
to the insurer on a Health Care Finance Administration 1500 form, UB 92 forms,
or any other standard form approved by the department for purposes of this billing.
All billings for such services shall, to the extent applicable, follow the Physicians’
Current Procedural Terminology . . . .” See Pressley, 28 So. 3d at 108 (holding
that the trial court erred in denying State Farm’s motion for summary judgment
because the medical providers’ bills were not submitted on the forms required by
section 627.736(5)(d), and therefore, no PIP benefits were overdue).
Although section 627.736(4)(b) provides that PIP benefits “shall be overdue
if not paid within 30 days after the insurer is furnished written notice of the fact of
a covered loss and of the amount of same,” section 627.736(5)(d) provides that
“[f]or purposes of paragraph 4(b), an insurer shall not be considered to have been
furnished with notice of the amount of covered loss or medical bills due unless the
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statements or bills comply with this paragraph.” Because the statement for
medical services rendered by Mariners Hospital did not comply with section
627.736(5)(d), State Farm did not receive notice of the PIP claim, and therefore,
the PIP benefits never became due. Pressley, 28 So. 3d at 108.
State Farm’s policy also specifically provides that if the PIP benefits are not
payable, the Med-Pay benefits are not payable because the Med-Pay benefits are
essentially excess coverage that is not implicated until PIP benefits are paid and
exhausted. See id. at 109 n.3. Because Gonzalez failed to comply with the notice
requirements under section 627.736 and her State Farm policy, State Farm had no
notice and no obligation to pay for the services Gonzalez claims she received and
claims are due. We therefore reverse the final judgment awarding Gonzalez PIP
and Med-Pay benefits and remand for entry of a final judgment in favor of State
Farm.
Reversed and remanded.
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