Friday, October 23, 2009

Third District Denies Certiorari In PIP Case Relating To 627.736(4)(b)

In Partners in Health Chiropractic, a/a/o Neocles Lebrun v. United Automobile Insurance Company (3D09-1418), the Third District denied a petition for certiorari and summarized as follows:
To summarize:
• a claim may be rejected more than thirty days after submission to the insurer notwithstanding being “overdue”;

• where no payment whatsoever has been made and the insurer rejects all claims or bills from a particular provider or treating physician as being unreasonable, unrelated or, unnecessary, section 627.736(4)(b) applies;

• where some but not all claims or bills from a particular provider or treating physician are being rejected or reduced as unreasonable, unrelated, or unnecessary, section 627.736(4)(b) likewise applies;

• Section 627.736(4)(b) requires only that an insurer have reasonable proof that a rejected claim or claims (or bill or bills) are unreasonable, unrelated, or unnecessary; while a section 627.736(7)(a) report may be utilized for this purpose, such a report is not required for this purpose;

• where an insurer withdraws (that is, terminates) payments being made to a treating physician or withdraws or terminates authorization for further treatment by a treating physician, a section 627.736(7)(a) report must first be obtained;

• such a section 627.736(7)(a) report does not have to be predicated on either a physical examination by the reporting physician or on a physical examination conducted on behalf of the insurer (an IME) but may be premised on review of the records of the insured’s treating physician.

In this case, the insurer made no payments, claiming that no treatment was reasonable, related or necessary. The Appellate Division therefore correctly concluded that this action was governed by section 627.736(4)(b) and that the trial court erred in refusing to consider either the affidavit or the report submitted by United Auto in support of its denial of Partners in Health’s claim. Although United Auto was not obligated to provide a section 627.736 (7)(a) report to support its rejection of Partners in Health’s claim, the Appellate Division was correct in determining that the report was valid even though not based on a physical examination conducted by the reporting physician.

For these reasons, and those stated in this opinion, the petition is denied.


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