Appellate Decision Holds That Medical Bills Submitted More Than 35 Days After Treatment Were Payable Based On Insured’s Failure To Provide Correct Information
Charlie Desaussure called on the services of the personal injury attorneys at Rue & Ziffra, P.A. to provide him legal guidance after being hurt in an automobile accident.
After Mr. Desaussure was injured in the automobile crash, he went to receive medical treatment at All Family Clinic of Daytona Beach (AFC) on October 9, 2007. Although Mr. Desaussure was insured under his mother’s automobile insurance policy with Direct General Insurance Company (Direct), which provided personal injury protection (PIP) benefits, he mistakenly did not tell his doctors at AFC that he was covered under that insurance policy. AFC contacted his attorney and case manager at Rue & Ziffra, P.A. about the availability of insurance but, at the time, the only information that was given was that Mr. Desaussure lived with his mother and that he might have PIP coverage through her. Mr. Desaussure never told AFC of his mother’s PIP coverage. Because of this mistake, AFC did not submit its medical bills to Direct within 35 days after it provided medical treatment to Mr. Desaussure (as required by Florida Statute 627.736(5)(c)1. )
On February 11, 2008, AFC received notice that Mr. Desaussure was indeed covered by his mother’s Direct policy and within 4 days of receiving the information it submitted the medical bills to Direct. Direct, however, denied payment of the bills, claiming they were not submitted within 35 days of the treatment rendered to our client. In response, AFC presented proof to Direct that it relied on Mr. Desaussure’s incorrect claim that he did not obtain any PIP coverage. Still, Direct denied the claim because it argued that AFC did not provide evidence that, in addition to receiving the incorrect information, the facility submitted the bills to an incorrect insurance carrier or a wrong address (which is the only exception to the 35 day submission rule as stated in 627.736(5)(c)2.)
Rue & Ziffra, P.A. filed suit on behalf of Mr. Desaussure against Direct but the trial court ruled in Direct’s favor. The court held that, since AFC was told that Mr. Desaussure might be covered though his mother’s insurance, they had the duty to properly investigate to determine whether there was coverage or not.
However, Rue & Ziffra, P.A. appealed this decision, and the Circuit Court sitting in its appellate capacity reversed the trial court’s prior ruling. In its opinion, the Circuit Court held that the PIP statute contained no requirement that a medical provider has to investigate whether the patient has coverage after it is told that no insurance is available. Further, since AFC received no insurance information at all, the part of the statute that mandates providers to show evidence saying they submitted medical bills to the wrong insurance carrier or address was inapplicable.
The court ruling stands for the proposition that as long as medical providers submit a patient’s medical bills within 35 days of the date they actually receive the correct insurance information, the bills are payable and have to be honored by automobile insurance companies.
This article was submitted by Social Security Disability attorney Luis Gracia, from Rue & Ziffra, P.A. Rue & Ziffra, P.A. is a Florida injury law firm located in Daytona Beach, serving those who are injured in various types of injury claims, from automobile accidents to medical malpractice claims.
Rue & Ziffra, P.A., proudly serves areas throughout Volusia County and Flagler County, Florida, including, Port Orange, Daytona Beach, New Smyrna Beach, Edgewater, Ormond Beach, Palm Coast, Flagler Beach, DeLand, Deltona, Bunnell, Orange City, Sanford, Orlando and Leesburg.
After Mr. Desaussure was injured in the automobile crash, he went to receive medical treatment at All Family Clinic of Daytona Beach (AFC) on October 9, 2007. Although Mr. Desaussure was insured under his mother’s automobile insurance policy with Direct General Insurance Company (Direct), which provided personal injury protection (PIP) benefits, he mistakenly did not tell his doctors at AFC that he was covered under that insurance policy. AFC contacted his attorney and case manager at Rue & Ziffra, P.A. about the availability of insurance but, at the time, the only information that was given was that Mr. Desaussure lived with his mother and that he might have PIP coverage through her. Mr. Desaussure never told AFC of his mother’s PIP coverage. Because of this mistake, AFC did not submit its medical bills to Direct within 35 days after it provided medical treatment to Mr. Desaussure (as required by Florida Statute 627.736(5)(c)1. )
On February 11, 2008, AFC received notice that Mr. Desaussure was indeed covered by his mother’s Direct policy and within 4 days of receiving the information it submitted the medical bills to Direct. Direct, however, denied payment of the bills, claiming they were not submitted within 35 days of the treatment rendered to our client. In response, AFC presented proof to Direct that it relied on Mr. Desaussure’s incorrect claim that he did not obtain any PIP coverage. Still, Direct denied the claim because it argued that AFC did not provide evidence that, in addition to receiving the incorrect information, the facility submitted the bills to an incorrect insurance carrier or a wrong address (which is the only exception to the 35 day submission rule as stated in 627.736(5)(c)2.)
Rue & Ziffra, P.A. filed suit on behalf of Mr. Desaussure against Direct but the trial court ruled in Direct’s favor. The court held that, since AFC was told that Mr. Desaussure might be covered though his mother’s insurance, they had the duty to properly investigate to determine whether there was coverage or not.
However, Rue & Ziffra, P.A. appealed this decision, and the Circuit Court sitting in its appellate capacity reversed the trial court’s prior ruling. In its opinion, the Circuit Court held that the PIP statute contained no requirement that a medical provider has to investigate whether the patient has coverage after it is told that no insurance is available. Further, since AFC received no insurance information at all, the part of the statute that mandates providers to show evidence saying they submitted medical bills to the wrong insurance carrier or address was inapplicable.
The court ruling stands for the proposition that as long as medical providers submit a patient’s medical bills within 35 days of the date they actually receive the correct insurance information, the bills are payable and have to be honored by automobile insurance companies.
This article was submitted by Social Security Disability attorney Luis Gracia, from Rue & Ziffra, P.A. Rue & Ziffra, P.A. is a Florida injury law firm located in Daytona Beach, serving those who are injured in various types of injury claims, from automobile accidents to medical malpractice claims.
Rue & Ziffra, P.A., proudly serves areas throughout Volusia County and Flagler County, Florida, including, Port Orange, Daytona Beach, New Smyrna Beach, Edgewater, Ormond Beach, Palm Coast, Flagler Beach, DeLand, Deltona, Bunnell, Orange City, Sanford, Orlando and Leesburg.
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