Florida law requires an automobile insurance policy to include $10,000 in personal injury protection (PIP) benefits. PIP covers medical treatment resulting from the accident, but there are limitations and procedural requirements. To be obligated to pay a claim, the insurer must receive proper notice of the loss. The recent case of State Farm Mutual Automobile Insurance Company v. Gonzalez addressed the issue of notice. The plaintiff in Gonzalez was treated at a hospital emergency room for injuries she received in an automobile accident in May 2001. The hospital bill was paid by her health insurance.
In January 2002, the plaintiff’s attorney sent a letter of representation to her automobile insurer. The letter stated the plaintiff was injured in the accident and requested insurance information. The attorney attached the police report, which indicated that the plaintiff had been transported to the hospital. The attorney’s letter did not include any documentation of the hospital’s charges or a demand for payment for those services.
According to the opinion, the automobile insurer repeatedly contacted the plaintiff’s counsel to request information and bills or statements for any treatment the plaintiff had received, but it did not receive a response and ultimately closed its claim in August 2004.
In May 2006, the plaintiff sued her insurer for uninsured motorist (UM) benefits. The UM claim was settled for $80,000. After settling the UM claim, the plaintiff’s counsel demanded the payment of personal injury protection (PIP) and Med-Pay benefits for the services rendered by the hospital and two other providers. The plaintiff filed suit for both the PIP and Med-Pay benefits. She ultimately abandoned her claims regarding the other two providers, one because the services had been rendered before the accident and the other because the lien for the services had been significantly reduced.
The automobile insurer moved for summary judgment, arguing that it had not received a statement of the charges as required under section 627.736(5)(d). The trial court denied the motion and entered judgment for the plaintiff of $685 in PIP and Med-Pay benefits for the hospital treatment.
The insurer appealed, arguing that it had not been provided with a bill or statement of the hospital charges, and it therefore had not been provided with proper notice of the claim.
The statute requires statements and bills for medical services to be submitted on specific claims forms using appropriate coding. Pursuant to section 627.736(4)(b), PIP benefits are overdue if they are not paid within 30 days of the insurer receiving written notice of the accident and the amount of loss, but an insurer is not considered to have received the notice if it does not comply with the requirements as to the forms. The information provided to the insurer did not meet the requirements listed in the statute.
Furthermore, the policy provided that Med-Pay benefits were not available if PIP benefits were not payable. The court found that, since the insurer had not received proper notice, it had no obligation to pay for the hospital services. The court reversed the trial court’s judgment and remanded for entry of judgment in favor of the defendant.
The court’s opinion does not provide much information as to what occurred in the years that transpired between the accident and the PIP lawsuit. The case does illustrate, however, how important it is to follow the procedural requirements regarding insurance claims.
It can be difficult to navigate all of the requirements of an insurance claim. If you have been injured in a car accident due to someone else’s negligence, the South Florida car accident attorneys at Anidjar & Levine can help you. Let us deal with the insurance companies while you focus on healing. Call (800) 747-3733, or submit an online contact form.
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