Monday, November 9, 2009

Explanation of benefits, valid medical reports and spicey cornbread

Insurance -- Personal injury protection -- Explanation of benefits -- Circuit court appellate division departed from essential requirements of law in affirming county court judgment finding that an insured has a private cause of action against a PIP insurer who fails to provide its insured an itemized specification of each item the insurer has reduced, omitted, or declined to pay within 30 days after the insurer is furnished written notice of the fact of a covered loss and the amount -- There is neither a requirement nor a deadline for a PIP insurer to respond to a request for payment -- A response is required from the insurer only when insurer either pays a portion of a claim or rejects a claim -- Insured has no private right of action against insurer for insurer's failure to provide an explanation of benefits to insured or insured's assignee in timely manner -- Appeals -- Case falls within limited category of cases in which district court is authorized to exercise discretion to review a circuit court appellate division per curiam affirmance of county court order or judgment
Reported at 34 Fla. L. Weekly D2268a

United Auto. Ins. Co. v. Santa Fe Medical Center ,(Fla.App. 3 Dist.)
Insurance - Insurer was not required to obtain valid medical report before denying a PIP claim.
The Florida District Court of Appeal has held that the subsection of the personal injury protection (PIP) statute providing that an insurer may not withdraw payment without the consent of the injured person, unless the insurer first obtains a valid report by another physician that the treatment was not reasonable, related, or necessary, does not require the insurer to obtain a valid medical report to deny payment of a PIP claim. Rather, this statute only requires that a valid report be obtained when further PIP benefits are withdrawn without the consent of the injured person. In so holding, the District Court of Appeal receded from United Auto. Ins. Co. v. Bermudez, to the extent that decision suggested that the medical report requirement applied to the denial of PIP benefits.

This decision may not yet be released for publication.

Insurance -- Coverage -- Waiver and estoppel -- Questions certified to Georgia Supreme Court: 1) Does an insurer effectively reserve its right to deny coverage if it informs the insured that it does “not see coverage,” after the insured had received a written reservation of rights from the insurer's sister company in a similar lawsuit in another jurisdiction, or is a written or more unequivocal reservation of rights required? 2) When an insurer assumes and conducts an initial defense without notifying the insured that it is doing so with a reservation of rights, is the insurer estopped from asserting the defense of noncoverage only if the insured can show prejudice, or is prejudice conclusively presumed? 3) If the insured must show prejudice, do the facts and circumstances of this case show it?
Reported at 22 Fla. L. Weekly Fed. C233a

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