United Auto. Ins. Co. v. Viles, 98-351
| Decision Date | 16 December 1998 |
| Docket Number | No. 98-351,98-351 |
| Citation | 726 So.2d 320 |
| Parties | UNITED AUTOMOBILE INSURANCE COMPANY, Appellant, v. Metelit VILES, Appellee. |
| Court | Florida District Court of Appeals |
Conroy, Simberg & Ganon and Hinda Klein, Hollywood, for appellant.
Deutsch & Blumberg and James C. Blecke, Miami; Sirven & Adams and Tony Sirven, Hialeah, for appellee.
Before JORGENSON, LEVY and GERSTEN, JJ.
As Amended on Denial of Rehearing En Banc March 10, 1999.
Appellant, United Automobile Insurance Company ("United Auto") appeals an order directing a verdict in favor of appellee, Metelit Viles ("Viles"), in a breach of contract claim for Personal Injury Protection ("PIP") benefits. We affirm based upon our conclusion that Section 627.736(7)(a), Florida Statutes (1997), requires an insurer to obtain a physician's report as a condition precedent to withdrawing or denying further medical payments.
Viles filed suit seeking PIP benefits for injuries allegedly sustained by Viles in an October 1995 car accident. United Auto answered and affirmatively defended that the chiropractic bills were fraudulent and not reasonably related to the accident in question. United Auto paid $1,100 to Viles before denying payment on the outstanding bills.
At the end of the trial, Viles moved for directed verdict arguing that Section 627.736(7)(a) required United Auto to first obtain a report from a similarly licensed physician before it could withdraw payment. Section 627.736(7)(a) provides in pertinent part:
Whenever the mental or physical condition of an injured person covered by personal injury protection is material to any claim that has been or may be made for past or future personal injury protection insurance benefits, such person shall, upon the request of an insurer, submit to mental or physical examination by a physician or physicians.... An insurer may not withdraw payment of a treating physician without the consent of the injured person covered by the personal injury protection, unless the insurer first obtains a report by a physician licensed under the same chapter as the treating physician whose treatment authorization is sought to be withdrawn, stating that treatment was not reasonable, related, or necessary.
According to Viles, because United Auto failed to comply with this statutory requirement, it was required to pay the entire amount of his chiropractic bills. The court reserved ruling, and the case was submitted to the jury.
The jury found that Viles had sustained reasonable and necessary medical bills of only $2,000. Since Viles had a $2,000 deductible and the verdict did not exceed that amount, United Auto argued that final judgment should be entered in its favor. However, despite these factual findings, the trial court granted Viles' renewed motion for directed verdict based upon Section 627.736(7)(a), finding that United Auto was barred from raising the defense that the bills were not reasonable or necessary, because it failed to obtain a physicians report prior to denying payment.
Final judgment was entered in favor of Viles in the amount of $3,632.00, the entire remaining sum owed to the doctor, and the trial court certified the following question of great public importance to this Court:
In any claim for personal injury protection benefits in which the insurance carrier has withdrawn, reduced benefits or denied further benefits, is it a condition precedent pursuant to Section 627.736(7)(a), Florida Statutes, that an insurer obtain a report by a physician licensed under the same chapter as the treating physician stating that the treatment was not reasonable, related or necessary in order for the insurance carrier to defend a suit for reduction, withdrawal or denial of further payments on the grounds of reasonableness, necessity or relationship?
We answer the certified question in the affirmative, and affirm the order below.
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...Holly v. Auld, 450 So.2d 217, 219 (Fla.1984); City of Boca Raton v. Gidman, 440 So.2d 1277 (Fla.1983); United Auto. Ins. Co. v. Viles, 726 So.2d 320 (Fla. 3d DCA 1998); Sullivan v. Fulton County Administrator, 662 So.2d 706 (Fla. 4th DCA 1995), approved, 675 So.2d 927 In addition, the Depar......
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