Noteworthy injury cases in South Florida
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In July of 2009 the 3rd District Court of Appeal (DCA) ruled on a Personal Injury Protection (PIP) matter. The insured’s medical provider filed suit against the insurer seeking the PIP benefits after the insurer denied payment of the provider’s bills. The trial court granted a motion for summary judgment for the medical provider. The Circuit Court appellate division in Miami-Dade County affirmed. Thus it was finally appealed to the 3rd DCA which held that the report of the physician relied upon by the insurer to justify denial of the PIP benefits was a valid report. Thus, the lower decisions were reversed.
How did this happen? Read on… The case is United Automobile Insurance Company v. Metro Injury & Rehab Center, 16 So.3d 897 (3rd DCA 2009).
In this case, United Auto insured a Ms. Davis via the PIP automobile insurance policy. Ms. Davis was involved in a car accident on April 2, 2005. She went to Metro and as is customary, she assigned to Metro her right to benefits under the policy. On September 15, 2005, United Auto notified Metro that it was denying payment based on a report by a Dr. Goldbert who had reviewed the accident report, medical records and statement of Ms. Davis’ treating physicians and who concluded that further treatment was not reasonable, necessary or related to the accident.
United Auto cited Florida Statute 627.736(7)(a) which basically states that in order for an insurer to withdraw or stop paying medical bills it has to obtain a valid report by a Florida physician who states that the treatment is not reasonable, related, or necessary and that the valid report is one that is prepared and signed by the physician examining the insured person or reviewing the treatment records of the injured person and is factually supported.
Metro sued United Auto for breach of contract seeking PIP benefits under the policy. The trial court granted Metro’s motion for summary judgment concluding that Dr. Goldberg’s peer review report was not a “valid report” under the statute. The trial court did so because it stated that the report was not based on an independent medical examination (“IME”).
This appellate court reviewed the statute and prior case law. Specifically, it reviewed the case United Automobile Insurance Co. v. Bermudez, 980 So. 2d 1213 (Fla. 3d DCA 2008) in which the 3rd DCA decided that a valid report under the statute for the withdrawal of PIP benefits does not have to be based upon a physical examination conducted by the actual physician preparing the report. Instead, it held that it may be based on a physical examination of the insured by another physician’s examination, but that the physician preparing the report does not have to personally examine the insured. He or she may base the report on another physician’s examination and that such report can be done by reviewing the treatment records of the injured person alone. An IME is not required in order for a report to be a “valid report.”
