Title XXXVII
Insurance
Chapter 627
Insurance Rates and Contracts
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627.736 Personal injury protection benefits required; exclusions, priority and claims.
(1) REQUIRED BENEFITS. An insurance policy that meets the security requirements set forth in s.627.733 is required to provide personal injury coverage to the named insured and to relatives living in the same home, unless they are excluded by s.627.747. It must also cover passengers, drivers, and any other person struck by a motor car and suffering bodily injuries while not occupants of a self propelled vehicle. Subject to paragraphs (4)(e) and (2), a maximum of $10,000 in medical benefits
a) Medical Benefits. –80% of the reasonable costs for medically needed medical, surgical and dental services including prosthetics, as well as ambulance, hospital and nursing care if you receive initial services within 14 days following the accident. Medical benefits are only reimbursed for:
1. Initial services and treatment that is lawfully provided, ordered or prescribed by a chiropractor physician licensed under Chapter 460 or a chiropractic doctor licensed under Chapter 458, by a registered advanced practice nurse licensed under s.464.0123, by a licensed physician or dentist under Chapter 466 or by a registered advanced practice registered nursing registered under s.464.0123, in a hospital, in an institution that owns or wholly owns a licensed hospital. Initial services and care can also be provided under part III chapter 401 by an entity or person licensed to provide emergency transportation and treatment.
2. Referrals from a provider described under subparagraph 1 will result in follow-up services and care that are consistent with the medical diagnosis made pursuant to subparagraph 1, which can only be provided, ordered or prescribed by a doctor licensed under chapters 458 and 459, a chiropractor licensed under Chapter 460, dentist licensed under Chapter 466 or an advanced registered nurse registered under section 464.0123. Or, to the extent allowed by law, and under supervision of a licensed physician assistant, osteopathic or chiropractic physician or dentist The following individuals or entities may also provide followup services and care:
a. A hospital or an ambulatory surgery center licensed under Chapter 395.
b. Entity wholly owned or controlled by one or more doctors licensed under Chapter 458 or Chapter 459, chiropractors licensed under Chapter 460, advanced-practice registered nurses registered pursuant to s.464.0123 or dentists licensed by chapter 466, as well as their spouses, parents, children, and siblings.
Entity that is owned or controlled by a hospital directly or indirectly.
d. A licensed physical therapist under chapter 486, based on a referral from a provider described in the subparagraph.
A clinic licensed under the part X of Chapter 400 that is accredited by a certifying body whose standards include comparable regulations as required by this State,
(I) Is a medical director licensed pursuant to chapter 458, 459 or 460?
(II). Has been continuously licensed by the United States Securities and Exchange Commission for at least 3 years, or is a publicly-traded corporation that trades securities on an exchange that has registered as a national security exchange with them.
The medical specialty (III) must include at least four specialties.
(A) General medicine.
(B) Radiography.
Orthopedics is a branch of medicine.
Physical Medicine
Physical Therapy (E)
Physical Rehabilitation (F)
Prescription or dispensing of outpatient prescription medications.
H) Laboratory Services
3. The reimbursement for services or care provided under subparagraphs 1. or 2. is up to $10,000, if the physician or dentist licensed under Chapter 458 or 459 or a physician assistant or advanced practice registered nurse licensed by chapter 458, 459 or 464 determined that an injured person was suffering from an emergency medical condition.
4. The reimbursement for services or care provided under subparagraphs 1. or 2. is limited at $2,500, if the provider listed in subparagraphs 1. or 2. determines that an injured person does not have a medical emergency.
5. Massage therapy, as defined by s. 480.033, and acupuncture (as defined by s. 457.102), regardless of who provides the massage therapy or acupuncture is not covered under medical benefits. A licensed massage therapist, or licensed acupuncturist, may not receive reimbursement for medical benefits.
6. The Financial Services Commission will adopt a rule that specifies the form to be used by insurers and health care providers as specified in subparagraphs 2.b., 2.c. or 2.e. Documentation that the health provider meets the criteria in this paragraph. A rule of this type must require a sworn declaration or affidavit.
(b) Disability Benefits. –60% of the loss of gross earnings and earning capacity of an individual due to the inability to work directly caused by their injury plus any expenses reasonably incurred for obtaining ordinary and necessary services from others in place of those which, but for the injuries, the injured would have performed for his or her family without income. All disability benefits due under this provision are to be paid every two weeks.
(c) Death Benefits. –Death benefits up to $5,000 per person. The death benefits are paid in addition to any medical or disability benefits that may be provided by the policy. The insurer can pay death benefits to an executor, administrator, or any other person who is a relative of the deceased by blood, adoption or marriage.
Only insurers who write motor vehicle liability policies in this state are allowed to provide the benefits required under this section. They may not, however, require that the purchaser of the property damage liability policy required by s.627.7275 purchase any other coverage for the motor vehicle as a prerequisite for receiving these benefits. Insurance companies cannot require property damage liability coverage in excess of $10,000 to be purchased with personal injury protection. These insurers must make the required coverage and benefits of property damage liability insurance available via normal marketing channels. A motor vehicle liability insurer in this state that fails to adhere to such availability requirements as a standard business practice is violating part IX. This violation constitutes unfair competition, or unfair or deceptive acts or practices involving insurance. The penalties for such a violation are set forth in that part as well as elsewhere in the Insurance Code.
(2) AUTHORIZED EXCLUSIONS.–Any insurer may exclude benefits:
(a) In the event of injury to the named insured or any family members living in the same household, while using another motor vehicle that is owned by the named insurer and not covered by the policy. This also applies for injuries sustained by anyone operating the insured vehicle without express or implied consent from the insured.
(b) Any injured person whose conduct has contributed to their injury in any of the following situations:
1. Intentionally injuring oneself;
2. Injured while committing a crime.
If an insured is accused of conduct described in paragraph (4)(b), the 30-day payment period of that paragraph shall be suspended, and any benefits under the personal injury protection scheme shall not be paid until the result of the trial. The 30-day payment period will begin to run when the insurer receives notification of the dismissal or nolle prossed charge, or if the insured has been acquitted.
(3) INSURED’S RIGHTS FOR RECOVERY OF SPEEDS DAMAGES IN TORT ACTIONS. –No insurer may have a lien over any recovery for personal injury benefits in tort, by judgment, settlement or other means, regardless of whether a suit was filed or if a settlement had been reached without bringing suit. A party injured by a motor vehicle accident who has the right to sue under ss. The person who is entitled to bring suit under ss. 627.730-627.7405 or their legal representative will not be able to recover damages for personal injury protection benefits that have been paid or are payable. Despite this limitation, the plaintiff can prove all special damages. However, if these damages are proven, then the judge or jury will not award damages in relation to personal injury protection benefits that have been paid or payable. The court must instruct juries in all cases where a jury has to determine damages that the plaintiff cannot recover special damages for benefits paid or payable under personal injury protection.
Benefits payable by an insurer are those provided under the ss. The benefits under sections 627.730-627.7405 take precedence, with the exception that any benefits received pursuant to a workers’ compensation act must be credited towards the benefits under subsection (1). Benefits are payable upon receipt of a reasonable proof of the loss and of the expenses and losses incurred covered by the policy issued by section 627.730-627.7405. 627.730-627.7405. The benefits of section 627.730-627.7405 are available if the Agency for Health Care Administration pays or is liable for medical aid under the Medicaid program relating to an injury, illness, disease or death that results from the ownership, maintenance or use of a vehicle. Medicaid covers 627.730-627.7405. The insurer must return the full amount of benefits paid by the Medicaid program within 30 days from the date they receive notice.
a) An insurance company may require that written notice be given as quickly as possible after an accident with a motor vehicle for which the policy provides the required security. 627.730-627.7405.
If the insurance company is not notified in writing of the covered loss, and the amount thereof, within 30 days of receiving the written notification from the insurer, the benefits are considered overdue. However:
1. In the event that the insurer does not receive written notification of the claim in its entirety, any amount paid by the insured within 30 days following the written notice will be considered overdue. If the insurer receives written notice of the entire claim, or a part of it, and the amount is not paid in 30 days following the written notice being given to them, the payment is considered overdue.
2. In the event that an insurer only pays a part of a claim (or rejects it), the insurer must provide, at the time of partial payment or refusal, an itemized description of each item the insurer has reduced, omitted or refused to pay, as well as any other information the insurer wants the claimant consider in relation to the medical necessity for the denied treatment, or to explain to the claimant the reasonableness or the reduced charge, if that does not restrict the introduction of evidence during trial. The insurer should also provide the claimant with the name and contact information of the person who will be receiving the response and the claim number that can be used in any future correspondence.
3. When an insurer rejects or pays only part of a claim because of an alleged mistake in the claim, it must provide a detailed specification or explanation to explain the benefits due to that error. The person who made the claim has 15 days from the date of receipt of the explanation or specification to make a revised claim. This is considered timely notice of the claim.
4. Payment is not late if there is reasonable proof from the insurer that they are not responsible for payment.
5. Payment is considered made when a check or other valid instrument equivalent to payment has been mailed to the United States in an envelope properly addressed and postpaid or, if the envelope was not posted, the day of delivery.
6. The paragraph does not limit or prevent the insurer from asserting that the claim is unrelated, not medically needed, unreasonable, or that the charge exceeds the maximum allowed under subsection (5) or violates it. This assertion can be made at any point, even after payment or the 30-day payment period set out in this paragraph.
After receiving notice that an accident may be covered by personal injury benefits, the insurer is required to reserve $5,000 in personal injury benefits. This money will then be paid out to doctors licensed under chapters 458 and 459, or dentists licensed in chapter 466, who are licensed in emergency care as defined in section 395.002 or provide hospital inpatient services. The insurer may use the amount held in reserve only to pay claims made by such dentists or physicians for up to 30 days following the date of receiving notice of the accident. The insurer may use any reserve amount for which it has not yet received notification of claims after the 30-day period. The time period specified in paragraph (b), for payment of personal injuries protection benefits, is tolled by the time an insurer must hold payment for a claim not from a physician or dentist if the personal injury benefits that are not held in reserve do not cover the claim. This paragraph does require that an insurer establish a reserve for claims accounting.
All overdue payment accrue simple interest, at the rate set forth in s.55.03, or the rate specified in the insurance policy, whichever rate is higher, for the quarter that the payment was overdue. Calculated from the date on which the insurer received written notification of the covered loss. The interest is due when the claim is paid.
(e) An insurer who insures the owner of a vehicle must pay benefits under personal injury protection for:
1. Injury to the body caused by a motor car, while the owner is occupying the vehicle or not in the vehicle.
2. Owner’s accidental bodily injury while in the motor vehicle, even if it occurred outside of this state but within the United States of America, its territories, possessions, or Canada.
3. Accidental bodily injuries sustained by a family member of the owner who lives in the same household under the circumstances described at subparagraphs 1. or 2., provided that the relative is a resident of the household of the owner and not the owner of an automobile for which security may be required. 627.730-627.7405.
4. If the injured person was not:
a. The owner of an automobile for which a security deposit is required pursuant to ss. 627.730-627.7405
b. The owner’s insurer is responsible for paying personal injury benefits.
(f) In the event that two or more insurers have a joint liability for paying benefits under the personal injury protection scheme for the same injury, the maximum amount payable is the one specified in paragraph (1). The insurer who pays the benefits has the right to recover an equitable pro-rata share from the other insurers of the benefits and expenses paid in relation to the claim.
Insurance code violation (g) If an insurer fails to provide timely benefits, as required by the section in a manner that is so frequent as to be a business practice, it constitutes a violation.
(h) Benefits will not be due to an insured person or paid on their behalf if they have committed insurance fraud in relation to the personal injury protection coverage of his or her policy. This fraud must either be admitted by the insured in a sworn declaration or proven by a competent court. Insurance fraud invalidates all coverage under the personal injury coverage of the person who committed fraud. This is true even if a portion or the claim was legitimate. Any benefits paid prior to the discovery of fraud are recoverable in full by the insurer from the person who committed fraud. In any case where the prevailing party prevails over an insurer to enforce their right to recovery under this paragraph, it is entitled to recover its costs and attorneys fees.
(i) An insurer who has a reasonable suspicion that an insurance fraud has occurred, as defined in s. 626.989 and s. 817.232, shall inform the claimant by writing within 30 days of receiving the claim, that it is under investigation for fraud. The insurer will have an additional 60-days to investigate fraud after the initial 30-day period. The insurer is required to deny or pay a claim within 90 days of its submission, notwithstanding paragraph (10). Interest is calculated from the date the claim was filed until the date the claim is paid. The Division of Investigative and Forensic Services must be notified of all claims denied due to suspected fraudulent insurance acts.
(j) The insurer must create and maintain a log for each insured of all personal injury protection benefits that the insurer has paid on behalf of the insured. The insurer must provide a copy to the insured within 30 days of receiving the request.
(5) CHARGES RELATED TO THE TREATMENT FOR INJURED PEOPLE.
The insurer may pay directly to the person or organization rendering the treatment, if, in the opinion of the insured, the guardian or the physician has countersigned a properly filled-out invoice, bill or claim form that was approved by the office on which the charges are to paid. The charge cannot exceed what the institution or person charges regularly for similar services or supplies. When determining if a charge is reasonable for a service, treatment or other service, evidence may be considered, such as the usual and customary payments and charges accepted by the provider in dispute, the reimbursement levels within the community, the federal and state medical fees schedules that apply to motor vehicle insurance and other coverages and any other relevant information.
1. The insurer can limit the reimbursement to 80 per cent of the maximum charges listed below:
a. For emergency transport or treatment by licensed providers under Chapter 401, 200% of Medicare.
b. 75 percent of the usual and customary hospital charges for emergency services or care provided by hospitals licensed under Chapter 395.
For emergency care and services as defined in s.395.002 rendered in a facility licensed pursuant to chapter 395 by a dentist or physician, and for related hospital inpatient service rendered by either a dentist or physician, the usual and standard charges in the locality.
For hospital inpatient care other than emergency and urgent services, 200 percent the Medicare Part A prospective payments applicable to the hospital that provides the inpatient service.
e. For outpatient hospital services other than emergency care and services, 200 percent the Medicare Part A Ambulatory Payment Classification of the hospital that provides the outpatient service.
For all other services, supplies and care, you can claim 200 percent of your allowable amount.
(I) The participating physicians fee schedule of Medicare Part B, except as provided in sub-sub-subparagraphs (II) and (III).
Medicare Part B (II) in the case services, supplies and care provided by ambulatory surgery centers and clinical labs.
(III) The Durable Medical Equipment Prosthetics/Orthotics and Supplies fee schedule of Medicare Part B, in the case of durable medical equipment.
If, however, such services or supplies are not reimbursed under Medicare Part B as stated in this sub-paragraph, then the insurer can limit reimbursements to 80 percent the maximum workers’ compensation allowance, which is determined by s.440.13, and the rules that were adopted under it, at the time the services or supplies or care was provided. The insurer is not required by law to reimburse services, supplies or care which are not reimbursable through Medicare or workers compensation.
2. The applicable Medicare Part B schedule for 2007 is used to determine the amount that can be charged for medical supplies and services that are subject to Medicare Part B. The term “service year”, for the purposes of this paragraph, means the period between March 1 and the end of February the following year.
3. The insurer is not allowed to limit the number of treatments, or any other usage limits, that are applicable under Medicare or Workers’ Compensation. Subparagraph 1. allows an insurer to reimburse providers who have lawfully performed care or treatments within the scope of their license. This is regardless of whether the provider has a right to reimbursement from Medicare because of restrictions on types of providers or disciplines that may be reimbursed. Subparagraph 1 does not prevent an insurer from using Medicare coding policies or payment methodologies, including applicable modifcations, to determine appropriate reimbursement for medical supplies, services or care, if they do not represent a utilization limitation.
4. The person who provides the services, supplies or care cannot bill or try to collect any amount above the limit set by the insurer, except in the case of amounts not covered by personal injury protection insurance due to coinsurance or policy maximum limits.
5. The insurer can only limit payments as allowed by this paragraph if, at the time the policy is issued or renewed, it includes an announcement that states the insurer has the right to limit payments according to the schedule of fees specified in this paragraph. This requirement is satisfied by a policy form that has been approved by the office. The insurer can pay the provider’s charge if it is less than the maximum allowed in subparagraph 1.
(b)1. (b)1.
a. A broker, or a person claiming on behalf of a Broker;
b. For any treatment or service that was illegal at the time it was rendered.
c. Any person who submits a false statement or a misleading one in relation to the claim;
If a bill, statement or other document does not meet the requirements set forth in paragraph (d),
To facilitate prompt payment of lawful services, an insurer may change codes that it determines have been improperly or incorrectly up coded or unbundled and make payment based on the changed codes, without affecting the right of the provider to dispute that change by the insurer. An insurer can change codes if it believes that they have been incorrectly up-coded or unbundled, and make payments based on those codes. This does not affect the provider’s right to dispute the change.
The physician’s invoice must include documentation proving that the physician was responsible for medical services rendered and billed.
2. In consultation with the professional licensing boards concerned, the Department of Health shall adopt a rule establishing a list of tests that are not medically necessary to use for the treatment of bodily injuries covered by the personal injury protection benefits provided under this section. The Department of Health will periodically review the list in consultation with professional licensing boards. Inclusion of a test on the list shall be based on lack of demonstrated medical value and a level of general acceptance by the relevant provider community and may not be dependent for results entirely upon subjective patient response. Notwithstanding its inclusion on a fee schedule in this subsection, an insurer or insured is not required to pay any charges or reimburse claims for an invalid diagnostic test as determined by the Department of Health.
(c) With respect to any treatment or service, other than medical services billed by a hospital or other provider for emergency services and care as defined in s. 395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 35 days before the postmark date or electronic transmission date of the statement, except for past due amounts previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement. The injured party is not liable for, and the provider may not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable.
1. If the insured fails to furnish the provider with the correct name and address of the insured’s personal injury protection insurer, the provider has 35 days from the date the provider obtains the correct information to furnish the insurer with a statement of the charges. The insurer is not required to pay for such charges unless the provider includes with the statement documentary evidence that was provided by the insured during the 35-day period demonstrating that the provider reasonably relied on erroneous information from the insured and either:
a. A denial letter from the incorrect insurer; or
b. Proof of mailing, which may include an affidavit under penalty of perjury, reflecting timely mailing to the incorrect address or insurer.
2. For emergency services and care rendered in a hospital emergency department or for transport and treatment rendered by an ambulance provider licensed pursuant to part III of chapter 401, the provider is not required to furnish the statement of charges within the time periods established by this paragraph, and the insurer is not considered to have been furnished with notice of the amount of covered loss for purposes of paragraph (4)(b) until it receives a statement complying with paragraph (d), or copy thereof, which specifically identifies the place of service to be a hospital emergency department or an ambulance in accordance with billing standards recognized by the federal Centers for Medicare and Medicaid Services.
3. Each notice of the insured’s rights under s. 627.7401 must include the following statement in at least 12-point type:
BILLING REQUIREMENTS.–Florida law provides that with respect to any treatment or services, other than certain hospital and emergency services, the statement of charges furnished to the insurer by the provider may not include, and the insurer and the injured party are not required to pay, charges for treatment or services rendered more than 35 days before the postmark date of the statement, except for past due amounts previously billed on a timely basis, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement.
(d) All statements and bills for medical services rendered by a physician, hospital, clinic, or other person or institution shall be submitted to the insurer on a properly completed Centers for Medicare and Medicaid Services (CMS) 1500 form, UB 92 forms, or any other standard form approved by the office and adopted by the commission for purposes of this paragraph. All billings for such services rendered by providers must, to the extent applicable, comply with the CMS 1500 form instructions, the American Medical Association CPT Editorial Panel, and the Healthcare Common Procedure Coding System (HCPCS); and must follow the Physicians’ Current Procedural Terminology (CPT), the HCPCS in effect for the year in which services are rendered, and the International Classification of Diseases (ICD) adopted by the United States Department of Health and Human Services in effect for the year in which services are rendered. All providers, other than hospitals, must include on the applicable claim form the professional license number of the provider in the line or space provided for “Signature of Physician or Supplier, Including Degrees or Credentials.” In determining compliance with applicable CPT and HCPCS coding, guidance shall be provided by the CPT or the HCPCS in effect for the year in which services were rendered, the Office of the Inspector General, Physicians Compliance Guidelines, and other authoritative treatises designated by rule by the Agency for Health Care Administration. A statement of medical services may not include charges for medical services of a person or entity that performed such services without possessing the valid licenses required to perform such services. For purposes of paragraph (4)(b), an insurer is not considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph and are properly completed in their entirety as to all material provisions, with all relevant information being provided therein.
(e)1. At the initial treatment or service provided, each physician, other licensed professional, clinic, or other medical institution providing medical services upon which a claim for personal injury protection benefits is based shall require an insured person, or his or her guardian, to execute a disclosure and acknowledgment form, which reflects at a minimum that:
a. The insured, or his or her guardian, must countersign the form attesting to the fact that the services set forth therein were actually rendered;
b. The insured, or his or her guardian, has both the right and affirmative duty to confirm that the services were actually rendered;
c. The insured, or his or her guardian, was not solicited by any person to seek any services from the medical provider;
d. The physician, other licensed professional, clinic, or other medical institution rendering services for which payment is being claimed explained the services to the insured or his or her guardian; and
e. If the insured notifies the insurer in writing of a billing error, the insured may be entitled to a certain percentage of a reduction in the amounts paid by the insured’s motor vehicle insurer.
2. The physician, other licensed professional, clinic, or other medical institution rendering services for which payment is being claimed has the affirmative duty to explain the services rendered to the insured, or his or her guardian, so that the insured, or his or her guardian, countersigns the form with informed consent.
3. Countersignature by the insured, or his or her guardian, is not required for the reading of diagnostic tests or other services that are of such a nature that they are not required to be performed in the presence of the insured.
4. The licensed medical professional rendering treatment for which payment is being claimed must sign, by his or her own hand, the form complying with this paragraph.
5. The original completed disclosure and acknowledgment form shall be furnished to the insurer pursuant to paragraph (4)(b) and may not be electronically furnished.
6. The disclosure and acknowledgment form is not required for services billed by a provider for emergency services and care as defined in s. 395.002 rendered in a hospital emergency department, or for transport and treatment rendered by an ambulance provider licensed pursuant to part III of chapter 401.
7. The Financial Services Commission shall adopt, by rule, a standard disclosure and acknowledgment form to be used to fulfill the requirements of this paragraph.
8. As used in this paragraph, the term “countersign” or “countersignature” means a second or verifying signature, as on a previously signed document, and is not satisfied by the statement “signature on file” or any similar statement.
9. The requirements of this paragraph apply only with respect to the initial treatment or service of the insured by a provider. For subsequent treatments or service, the provider must maintain a patient log signed by the patient, in chronological order by date of service, which is consistent with the services being rendered to the patient as claimed. The requirement to maintain a patient log signed by the patient may be met by a hospital that maintains medical records as required by s. 395.3025 and applicable rules and makes such records available to the insurer upon request.
(f) Upon written notification by any person, an insurer shall investigate any claim of improper billing by a physician or other medical provider. The insurer shall determine if the insured was properly billed for only those services and treatments that the insured actually received. If the insurer determines that the insured has been improperly billed, the insurer shall notify the insured, the person making the written notification, and the provider of its findings and reduce the amount of payment to the provider by the amount determined to be improperly billed. If a reduction is made due to a written notification by any person, the insurer shall pay to the person 20 percent of the amount of the reduction, up to $500. If the provider is arrested due to the improper billing, the insurer shall pay to the person 40 percent of the amount of the reduction, up to $500.
(g) An insurer may not systematically downcode with the intent to deny reimbursement otherwise due. Such action constitutes a material misrepresentation under s. 626.9541(1)(i)2.
(h) As provided in s. 400.9905, an entity excluded from the definition of a clinic shall be deemed a clinic and must be licensed under part X of chapter 400 in order to receive reimbursement under ss. 627.730-627.7405. However, this licensing requirement does not apply to:
1. An entity wholly owned by a physician licensed under chapter 458 or chapter 459, or by the physician and the spouse, parent, child, or sibling of the physician;
2. An entity wholly owned by a dentist licensed under chapter 466, or by the dentist and the spouse, parent, child, or sibling of the dentist;
3. An entity wholly owned by a chiropractic physician licensed under chapter 460, or by the chiropractic physician and the spouse, parent, child, or sibling of the chiropractic physician;
4. A hospital or ambulatory surgical center licensed under chapter 395;
5. An entity that wholly owns or is wholly owned, directly or indirectly, by a hospital or hospitals licensed under chapter 395;
6. An entity that is a clinical facility affiliated with an accredited medical school at which training is provided for medical students, residents, or fellows;
7. An entity that is certified under 42 C.F.R. part 485, subpart H; or
8. An entity that is owned by a publicly traded corporation, either directly or indirectly through its subsidiaries, that has $250 million or more in total annual sales of health care services provided by licensed health care practitioners if one or more of the persons responsible for the operations of the entity are health care practitioners who are licensed in this state and who are responsible for supervising the business activities of the entity and the entity’s compliance with state law for purposes of this section.
(6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.–
(a) If a request is made by an insurer providing personal injury protection benefits under ss. 627.730-627.7405 against whom a claim has been made, an employer must furnish, in a form approved by the
A sworn statement detailing the earnings of the injured person since the date of injury. This should include a period of time before the injury.
If this does not restrict the use of evidence in court, the physician, hospital or clinic must provide a written statement stating that the treatment rendered was reasonable and necessary in light of the injury suffered and that the costs incurred for the treatment were a direct result of that injury. They also have to allow for the inspection and copying their records relating to such history, conditions, treatments, dates and costs. This sworn statement should read: “Under penalties of perjury I declare that I’ve read the above, and the facts are true to the best my knowledge and beliefs.” The person who requests such records and such sworn statements shall pay for all reasonable costs associated with them. The amount or partial amount, which is the subject matter of an insurer’s request under this paragraph is due if it is not paid within 10 days of receipt or if the insurer fails to pay according to paragraph (4) (b). The term “receipt”, as used in this section, includes but is not restricted to inspection and copying. A business that asks for documentation or information regarding the reasonableness of charges, or medical necessity in this paragraph and does not have a reasonable reason to do so is engaged in unfair trade practices under the Insurance Code.
If there is a dispute over the right of an insurer to discover facts under this section the insurer can petition a court with jurisdiction to issue an order allowing such discovery. The order can only be issued on motion and after notice to all parties with an interest. It must also specify the date, time, location, method, conditions and scope of discovery. To protect against embarrassment or harassment, the court can enter an order refusing or specifying the conditions of discovery. It may also order payment of costs and expenses, including reasonable attorney fees, if justice so requires.
(d) On request, the injured person must receive a copy all the information obtained by an insurer in accordance with this section and pay any reasonable charges if the insurer so requests.
The insured may not withhold notice of a claim from an insurer.
If the insurer is asked to do so, it must inform the insured, or an assignee, within 15 days of the limit being reached.
(g) A person seeking benefits under the ss. The terms of 627.730-627.7405 must be followed, and this includes, but is not limited to, an examination under oath. The scope of the questions during an examination under oath will be limited to pertinent information or to information that can reasonably lead to relevant data. The compliance with this paragraph must be met before benefits can be received. The s.626.9541 applies to an insurer who, without reasonable cause, and as part of its general business practices, asks an insured or omnibus insured to be examined under oath.
(7) MENTAL & PHYSICAL ANALYSIS OF INJURED PERSONS; REPORTS.
a) When the mental or bodily condition of a person injured by personal injury insurance is relevant to a claim for past or future benefits under personal injury insurance, the person must, at the insurer’s request, undergo a mental or medical examination by one or more physicians. All costs associated with any examinations ordered by an insurer are to be paid by that insurer. The examination must be performed in the municipality of the insured or at a place that is reasonably accessible by the insured. This includes any location in the municipality of the insured or within 10 miles of their residence, as long as it is in the county of the insured. In the event that the examination must be performed in a place reasonably accessible to an insured and there is not a qualified physician available to perform the examination, the examination will be conducted at the nearest location to their residence. Personal injury protection insurers may include reasonable provisions for the mental and physical examinations of individuals claiming benefits under personal injury insurance. The insurer cannot withdraw payment to a treating doctor without consent from the injured person covered under personal injury protection unless it first obtains a valid, signed report by a Florida licensed physician who is in the same chapter of Florida as the treating physician, which states that the treatment was not reasonable or necessary. Valid reports are those that have been signed and prepared by the doctor who examined the injured patient or reviewed the treatment records. They must also be factually supported and not altered by anyone else. A physician must be physically disabled and not in active practice to prepare the report. Active practice is defined as the time the physician spent in the three years prior to the date of the physical exam or review of treatment records, evaluating, diagnosing, or treating medical conditions, or instructing students at an accredited residency or health professional program, or participating in a clinical research project affiliated with a teaching hospital, accredited residency, or health professional program. Physicians preparing reports at the request of insurers, and physicians providing expert opinions for persons claiming personal injury protection or for an insured via an attorney or other entity, must maintain for at lease 3 years copies of all examinations reports as medical records, and they must also maintain for at least three years records of payments for examinations and reports. The insurer or any person acting on its behalf or at its direction may not materially alter an opinion expressed in a report prepared pursuant to this paragraph, nor can they direct a physician to do so. Denial of payment due to a change in opinion is a material misrepresentation as defined in s.626.9541(1) (i)2. However, this provision doesn’t prevent the insurer from bringing the errors in fact contained in the report to the physician’s attention based on information found in the claim file.
(b) On request by the person being examined, the party who causes the examination shall provide a copy to that person of each written report relating to the examination performed by an examining doctor, of which at least one must detail the findings and conclusions of the examining physicians. The party who ordered the examination is entitled to request the person examined to provide any written reports that he or she or their representative may have regarding previous or subsequent examinations of the same physical or mental condition. The person examined waives all privileges he or she might have in relation to a claim for benefits regarding testimony from any other person who may examine him or her at a later date in regard to the same mental condition or physical condition. The personal injury insurance carrier will no longer be liable for any personal injury benefits if a person refuses or does not appear at an exam in a reasonable manner. A refusal by an insured to submit or a failure to appear for two examinations creates a presumption of unreasonableness.
1(8) APPLICABILITY of PROVISION REGULATING ATTORNEY FEE.–In respect to any dispute arising under the provisions ss. The provisions of s.
(a) Adhere to the current professional standards.
(b) Do not overstate or inflate hours that are reasonably required for a similar case with comparable complexity or skill;
Represent reasonable and necessary legal services to obtain the desired result.
On request from either party, the judge must issue written findings, supported by evidence provided at trial or hearings related to it, that any award for attorney fees is in compliance with this section. Attorney fees are recovered under the ss. The calculation of the 627.730-627.7405 section must not take into account a contingency multiplier.
(9) PREFERRED PROVIDERS. — An insurer can negotiate and contract with preferred provider for the benefits described here, including health care providers licensed in accordance with chapter 458, chapter 461, chapter 462, or chapter 463. If the requirements of this section are met, the insurer can offer an option for an insured to choose a preferred provider when purchasing a policy to receive personal injury protection benefits. The insurer must provide the required medical benefits if the insured chooses to use another provider than the preferred provider. This applies whether the insured has a policy with a preferred or nonpreferred provider. The insurer can pay more than the medical benefits that are required under this section if the insured chooses to use a preferred provider. It may also waive or reduce the amount of the deductible for such medical benefits. The insurer must offer both a preferred and nonpreferred policy to policyholders or applicants. The insurer must provide each insured with the current list of preferred providers for the county where the insured lives at the time the policy is purchased. This list shall be available to the public during normal business hours in the insurer’s main office in the state.
DEMAND NOTE – LETTER 10
The insurer must receive written notice that the intention to file a lawsuit is a prerequisite to filing any claim for benefits under this article. This notice cannot be sent until after the claim has been overdue.
The notice must specify that it is “a demand letter under s.627.736”, and include specific details:
1. If the claimant does not represent the insured, the name of the person on whose behalf the benefits are sought. A copy of the assignment granting rights to the claimant should also be provided.
2. The claim number, or the policy number on which the claim was initially submitted to an insurer.
3. The name of the medical provider, if applicable, who provided the treatment, services or accommodations that are the basis for the claim, as well as an itemized statement stating the exact amount of each treatment, service or accommodation and the type or benefit claimed. The itemized statement can be a completed form that meets the requirements of paragraph (d) or a lost-wage statement. If the demand is a result of an insurer withdrawing payment for future treatment that has not yet been rendered under paragraph (7)a), the claimant must attach a copy the insurer’s notice of withdrawal and an itemized list of the types, frequency and duration of treatment the claimant claims to be reasonable and necessary.
(c) All notices required by this paragraph must be sent to the insurance company by certified or registered US mail with return receipt. The insurer will reimburse the postal costs if the claimant requests it in the notice. This reimbursement is made when the insurer pays the claims. This notice must be sent by the insurer to the address and person specified for receiving notices in accordance with this paragraph. The office will post the name and the address of each licensed insurer on its website. If no other designation is made, the name and address filed with the office under s.624.422 will be deemed to be the authorized representative for this subsection.
No action can be brought against an insurer if, within 30 calendar days of receiving the notice, it pays the overdue claim, along with any applicable interest, and a 10 percent penalty on the amount overdue, up to a maximum of $250. The insurer may not be sued if it withdraws payment for future treatment under paragraph (7)a). If this is the case, then the insurer must mail to the person who filed the notice within 30 days of receiving the notice an agreement that the insurer will pay for the treatment according to the notice. If the insurer decides to not pay the amount demanded, then the penalty will not be payable. Payment or the insurer’s agreement is treated as made when a draft, other valid instrument equivalent to payment, the written statement of agreement of the insurer, or properly addressed and postpaid envelope is placed into the United States Mail, or, if it is not posted, the date of the delivery. If the insurer has paid the claim within the specified time, or mailed its agreement to pay future treatment in a properly addressed and postpaid envelope, it is not required to pay attorney fees.
The 30-day limitation period for actions under this section will be extended by 30 days if the required notice is sent.
(1) FAILURE TO PAY CLAIMS VALID; UNFAIR AND DECEPTIVE PRACTICE.
The office is empowered to carry out the duties and powers specified by the ss. 626.9561-626.9601 If the insurer engages in a practice that is so frequent as to be indicative of a business general:
1. If you fail to pay valid personal injury claims;
2. Failing to pay valid claims before receiving the required notice as per subsection (10).
(b) Notwithstanding the s.501.212 the Department of Legal Affairs can investigate and initiate action for a violation of the subsection. This includes, but is not limited to the powers and duties described in part II of Chapter 501.
A person who prevails in an action brought under this subsection may recover compensatory, consequential, and punitive damages, subject to the requirements and limitations of part II of chapter 768, as well as attorney’s fees, costs, and expenses incurred during litigation. The insurer who prevails in an action brought pursuant to this subsection can recover compensatory and consequential damages, punitive damage, attorney’s fees, and costs, subject to the limitations and requirements of part II chapter 768.
(13) MINIMUM COVERAGE. — If the Financial Services Commission determines the savings in personal injury protection insurance benefit payments by insurers were realized because of the provisions of the act, previous legislative reforms or other factors the commission can increase the $10,000 minimum coverage requirement. The commission will determine the increase by comparing the cost savings realized on personal injury protection insurance coverage of $10,000 with the extra premium.
(14) FRAUD ADVICE NOTICE. – Upon receiving a claim filed under this section, the insurer must provide a notification to an insured person or a third party for whom a reimbursement claim has been made for treatment or diagnosis of injuries. The notice shall advise that:
According to section 626.9892 of the Financial Services Act, the Department of Financial Services can pay up to $25,000 in rewards to anyone who provides information that leads to the arrest or conviction of individuals suspected of crimes by the Division of Investigation and Forensic Services. These crimes are a result of violations of sections 440.105 and 624.15 of the Criminal Code, as well as sections 626.9541 and 626.989 of the Civil Code.
If you are contacted by someone injured in an accident, and they want to file a personal injury claim or a tort claim, this could be a violation of the Florida Bar rules, the Florida Bar statutes, or the s.817.234.
(15) ALL CLAIMS MUST BE BRINGED IN A SINGLE COURT ACTION. –In any civil suit brought pursuant to the provisions of this section by a claimant against an insurance company, all claims relating to the same provider of health care for the same injured party must be brought together in a single action unless there is good reason to separate them. The court cannot award attorney fees to a claimant if the court finds that the civil action was filed for a claim which should have been brought as part of a previous civil action.
(16) SECURE E-DATA TRANSFER. –An notice, documentation or transmission of any type required or authorized by ss. The 627.730-627.7405 can be sent electronically, if the transmission is done by a secure electronic data transfer in compliance with federal and state privacy and security laws.
(17) NONREIMBURSABLE ACTIONS.–Actions that are illegal pursuant to the s. 817.505 are not reimbursed under Florida Motor Vehicle No-Fault Law.
1Note.–
A. A. Section 2023-15 states that “[t]his Act shall not be construed as impairing any right under an Insurance Contract in effect before or on [March 24,2023]. This act, to the extent it affects an insurance right, applies to any insurance contract issued after [March 24, 2020].
B. The section 30 of ch. Section 30 of ch.