United Automobile Insurance Co. v. a 1st Choice Healthcare Systems
2009 Fla. App. LEXIS 16376, 21 So. 3d 124, 2009 WL 3616293 (2009)
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Rule of Law:
A statute that specifies penalties for an insurer's failure to pay a claim on time, such as interest and attorney's fees, does not create an implied private right of action for nominal damages based solely on the insurer's procedural failure to provide a timely Explanation of Benefits (EOB). A private right of action must be expressly intended by the legislature and cannot be implied from the statute's text.
Facts:
- On February 6, 2004, United Automobile Insurance Company's insured, Turner Plante, was injured in a car accident.
- Plante received medical treatment from A 1st Choice Healthcare Systems, Inc. from February 9 to February 16, 2004.
- On March 8, 2004, A 1st Choice, acting as Plante's assignee, submitted a request for payment for the medical services to United Auto.
- Thirteen months later, on April 12, 2005, United Auto responded with a form Explanation of Benefits (EOB).
- The EOB form indicated that the bill was not submitted properly and referenced an attached peer review, but no attachment was included.
Procedural Posture:
- A 1st Choice Healthcare Systems, Inc. filed a two-count complaint against United Automobile Insurance Company in county court (trial court).
- Count I sought payment of benefits, while Count II sought nominal damages for failure to provide a timely EOB.
- A 1st Choice voluntarily dismissed Count I.
- The county court granted summary judgment for A 1st Choice on Count II, awarding $1 in nominal damages and later $19,530.13 in attorney's fees and costs.
- United Auto, as appellant, appealed the judgment to the circuit court appellate division (intermediate appellate court).
- The circuit court appellate division affirmed the trial court's decision without a written opinion (per curiam).
- United Auto then petitioned the District Court of Appeal of Florida for a writ of certiorari to review the circuit court's affirmance.
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Issue:
Does section 627.736(4)(b) of the Florida Statutes create a private right of action for an insurer's failure to provide an insured with a timely Explanation of Benefits (EOB)?
Opinions:
Majority - Shepherd, J.
No, section 627.736(4)(b) does not afford a private right of action against an insurer for failing to meet a deadline for submission of an EOB. First, the court reasoned that the plain language of the statute does not impose a strict 30-day deadline for an insurer to respond with an EOB; rather, the EOB is required only at the time the insurer partially pays or rejects a claim. The statute's 30-day period makes a valid claim 'overdue,' which triggers penalties like interest and attorney's fees for non-payment, but it does not create an independent deadline for a response. Second, and more critically, a private right of action for a statutory violation only exists if the legislature intended to create one. The court found nothing in the text of section 627.736(4)(b) to suggest such an intent, noting that a right of action cannot be implied and that the statute's only authorized cause of action is for the payment of benefits themselves.
Analysis:
This decision clarifies that remedies for an insurer's procedural non-compliance under Florida's PIP statute are confined to the specific penalties enumerated within that statute, such as interest on overdue payments or attorney's fees in a suit for benefits. It prevents the creation of a separate, independent cause of action for purely procedural violations like failing to provide a timely EOB. This ruling reinforces the judicial principle of strict construction regarding statutory remedies, meaning courts will not imply a private right to sue where the legislature has not explicitly provided one, thereby discouraging litigation over procedural missteps separate from the core dispute over payment.
