Griselda Rubio v. State Farm

December 20, 2019, PIP, invalid pre-suit demand, failure to comply with conditions precedent, Summary Judgment

Style: Spine Correction f/k/a Alignlife a/a/o Griselda Rubio v. State Farm

Venue: County Court, Polk County, Florida

On May 13, 2018, State Farm’s insured, Griselda Rubio, was a restrained passenger in a motor vehicle involved in a rear end collision on Interstate 4. The insured sought medical treatment with the Plaintiff provider, Alignlife, between June 8, 2018 and October 29, 2018.

Upon receipt of Alignlife’s billing, State Farm issued payments for the services, totaling $15,000, in accordance with the Fla. Stat. 627.736, the policy language, the Medicare Part B fee schedules, and the Worker’s Compensation fee schedules until all benefits became exhausted.

On January 14, 2019, the Plaintiff medical provider served State Farm with a pre-suit demand pursuant to Florida Statute 627.736(10) alleging State Farm owed an additional $3,810.39 in PIP benefits for dates of service of June 8, 2018 through October 29, 2018. Fla. Stat. 627.736(10) requires that the provider serve a pre-suit demand at least thirty (30) days prior to the initiation of litigation. The demand is required to include a copy of the assignment of benefits and an itemized statement specifying each exact amount, the date of treatment, and the type of benefit claimed to be due.

Attached to the correspondence was a copy of the Plaintiff’s billing ledger, detailing all dates of service, the total billed by Plaintiff, and the total paid by State Farm. This ledger identified a total patient balance due and owing of $5,351.07. The ledger contained a column entitled “Insurance Responsibility” which identified a total insurance balance due and owing of negative $38.89. Thus, the amount alleged to be due and owing in the pre-suit demand was contradicted by the Plaintiff’s own billing ledger.

Following the filing of suit by Plaintiff, Defendant proceeded with a Motion for Summary Judgment for Failure to Comply with Conditions Precedent. Defendant argued that the Court must apply a strict compliance standard to the requirements of Fla. Stat. 627.736(10), the internal inconsistency between the demanded amount and the account balance fails to strictly comply with the requirements of the statute, and that Summary Judgment, not abatement, is the appropriate remedy.

Plaintiff argued for substantial compliance with the statutory requirements and took the position that a provider cannot know the exact amount of benefits due and owing and that it is the responsibility of the carrier to determine the amount due.

In the first ruling on strict vs. substantial compliance with Fla. Stat. 627.736(10) in Polk County, the Court held that the appropriate standard is strict compliance, the Plaintiff bears the responsibility of determining the amount due and owing when sending a pre-suit demand, and that Plaintiff’s demand failed to strictly comply with that responsibility due to the internal inconsistencies between the demand and the billing ledger.

The Court granted final summary judgment in favor of State Farm with no damages being awarded to Plaintiff.