Florida/Georgia Personal Injury & Workers Compensation

...Shaw at that time.” On May 7, 2001, Shaw sued Connecticut General in the Circuit Court of the Twelfth Judicial Circuit in Sarasota County, Florida, claiming that he was improperly denied long-term disability benefits and waiver of life insurance premium benefits in violation of Florida Statute § 627.613, which governs the timely payment of insurance claims....

...Westside's general allegations concerning the prompt pay provision of section 641.3155, alleging that the HMOs failed to make payment or contest payment within forty-five days. Westside specifically alleged violations of section 641.3155 as well as section 627.613, Florida Statutes (2001), in the other two counts of its amended complaint. Section 627.613 provides time periods in which health insurers must pay claims for medical services....

...s for each of the twenty-seven claims at issue. By the time of closing arguments, counsel for the Schusters conceded that the Schusters' damages "for the purposes of this case are going to be the statutory interest or the contractual interest on the 627.613." BCBSF continued to insist that the Schusters could not prevail because damages was an element of a cause of action for breach of contract and the Schusters had not sustained any damages....

...Damages Next, the Schusters maintain that even when the assignments of benefits to the providers are taken into account, the judge was incorrect in finding that they did not sustain any damage as the result of untimely payment by BCBSF. Clearly, both the insurance contract and section 627.613, Florida Statutes, require the insurer to pay interest on overdue payments....

...4th DCA 1992), rev. denied, 618 So.2d 210 (Fla. 1993); Atlantic Nat'l Bank of Fla. v. Vest, 480 So.2d 1328, 1331 (Fla. 2d DCA 1985), rev. denied, 491 So.2d 281 (Fla. 1986), rev. denied, 508 So.2d 16 (Fla. 1987). Third, assuming without deciding, that section 627.613(2), Florida Statutes (Supp....

...d because (1) Provident was not prejudiced by his untimeliness, and (2) Provident is estopped from asserting untimeliness as a basis for denying the claim because of its own delay in denying or granting the claim, in contravention of Florida Statute § 627.613 (1997) and Florida case law....

...ed itself in 1995. Accepting this evidence as true for the purposes of this motion, Provident is not, as a matter of law, estopped from contesting Lane's claim. The first legal justification offered by Lane for his estoppel theory is Florida Statute § 627.613 (1997). [25] Florida Statute § 627.613(2) (1997) provides: Health insurers shall reimburse all claims or any portion of any claim from an insured or an insured's assignees, for payment under a health insurance policy, within 45 days after receipt of the claim by the health insurer....

...ts, was squarely rejected by the Florida District Court of Appeal in Pioneer Life Insurance Company v. Heidenfeldt, 773 So.2d 75 (Fla. 2d DCA 2000). In that case, the court specifically found that "a failure to comply with the notice requirements of section 627.613(2) does not result in a forfeiture of an insurer's right to deny benefits when the benefits sought are excluded from the insurance coverage." Id....

...at 77. Rather, the court found that the only penalty for late notice by the insurer was that included in the express language of the statute — a ten percent interest on all overdue payments. Id. at 77. Therefore, as a matter of law, Florida Statute § 627.613(2) (1997) simply will not support Lane's theory of waiver or estoppel of Provident's defenses....

...14. [23] See Plaintiff's Memorandum in Opposition To Defendant's Motion for Summary Judgment, p. 14. [24] See Provident's Reply to Lane' Memorandum in Opposition to Motion for Summary Judgment, p. 12. [25] Lane cited section (a) of Florida Statute § 627.613 (1997). However, there is no section (a). Therefore, the Court has assumed that Lane is relying on § 627.613(2) (1997), which contains language similar to that paraphrased by Lane....

...interest on the payment and attorney's fees. Buttressing the decisions of the Fourth and Fifth District, is the Second District's opinion in Pioneer Life Insurance v. Heidenfeldt, 773 So.2d 75 (Fla. 2d DCA 2000). In Heidenfeldt, the court held that section 627.613, Florida Statutes (1997), which is substantially similar to section 627.736(4), Florida Statutes (Supp.1996), subjects an insurer to a ten percent interest penalty if it does not timely reimburse an insured, but does not prohibit the insurer from defending the claim if it does not timely reimburse....

...Pioneer Life Insurance ("Pioneer Life") appeals from a final judgment in favor of Belva Heidenfeldt. Pioneer Life asserts that the trial court incorrectly concluded that Pioneer Life was prohibited from denying insurance benefits due to its failure to comply with the notice requirements of section 627.613(2), Florida Statutes (1997)....

...Medicare paid a portion of Heidenfeldt's medical costs. On October 7, 1996; January 28, 1997; and May 20, 1997, Gulf Coast submitted claims to Pioneer Life for the remaining portion totaling $24,380. Pioneer Life failed to respond to the claims within the 45-day time period required under section 627.613(2)....

...Heidenfeldt filed a complaint against Pioneer Life seeking payment for the medical costs. Heidenfeldt then moved for summary judgment asserting that Pioneer Life was barred from denying coverage because it failed to comply with the 45-day notice requirement of section 627.613(2)....

...ility. The trial court later entered a final judgment awarding Heidenfeldt $29,283.16 in damages. This case requires us to determine whether the legislature intended that an insurance company's failure to comply with the 45-day notice requirement of section 627.613(2) prohibits the insurer from subsequently denying a claim on the basis that the benefits sought were expressly excluded from the insurance coverage....

...definite meaning, there is no occasion for resorting to the rules of statutory interpretation and construction.'" McLaughlin v. State, 721 So.2d 1170, 1172 (Fla.1998) (quoting A.R. Douglass, Inc. v. McRainey, 102 Fla. 1141, 137 So. 157, 159 (1931)). Section 627.613, Florida Statutes (1997), provides, in part: (1) The contract shall include the following provision: "Time of Payment of Claims: After receiving written proof of loss, the insurer will pay monthly all benefits then due for (type of benefit) ....

...The notice that a claim is contested shall identify the contested portion of the claim and the reasons for contesting the claim. . . . (6) All overdue payments shall bear simple interest at the rate of 10 percent per year. Pioneer Life asserts that the only penalty the legislature intended an insurer to incur under section 627.613(2) for failing to comply with the notice requirements is the ten percent interest penalty imposed by subsection (6). We agree. Pursuant to section 627.613(2), an insurer is required, within 45 days after receipt of a claim, to either reimburse the claim or notify the insured that the claim is contested or denied. Section 627.613(6) provides that all overdue payments will bear interest at the rate of ten percent....

...to reimburse a claim or notify an insured that the claim is contested or denied within the 45-day time period, the insurer would be subject to the ten percent interest penalty. This appears to be the only penalty an insurer would be subject to under section 627.613. This conclusion is supported by the Florida House of Representatives' Final Staff Analysis and Economic Impact Statement for the 1990 amendments to section 627.613....

...In the section related to direct private sector cost the statement reads, "This bill will increase expenses to insurers if they do not pay claims within 30 working days." See Staff of Fla. H.R. Comm. on Insurance, SB 970 (1990) Staff Analysis 3 (final June 19, 1990) (on file with comm.). Section 627.613 was subsequently amended in 1991 to increase the number of days insurers had to pay a claim to 45 days (calendar days). The language in the statement supports the conclusion that the legislature intended the ten percent interest provision of section 627.613(6) to be the only penalty, at least in regard to section 627.613, for an insurer's failure to pay or respond to an insured's claim within the statutory time limits....

...The supreme court reasoned that to rule otherwise would in effect "give insurance coverage to Block Marina ... at a time when the marina operator's legal liability endorsement had been eliminated from the policy and the contract of insurance expressly excluded such losses from coverage." Id. Based on our reading of section 627.613, we hold that a failure to comply with the notice requirements of section 627.613(2) does not result in a forfeiture of an insurer's right to deny benefits when the benefits sought are excluded from the insurance coverage....

...eed to undertake. See AIU Ins. Co., 544 So.2d at 999. While we understand the trial court's disapproval of the actions of this insurer in delaying ten months before informing Heidenfeldt that her claim would be denied, the legislature did not intend section 627.613 to act as a bar to denying uncovered claims. We, however, point out that there are other penalties insurers may be subject to, outside the scope of section 627.613, if they fail to comply with the requirements of the statute....

...this opinion. Reversed and remanded. THREADGILL, A.C.J., and ALTENBERND, J., Concur. NOTES [1] For example, Florida Administrative Code rule 4-142.011(9)(a)5 provides for penalties of up to $10,000 per violation for knowing and willful violations of section 627.613 and penalties of up to $2,000 per violation for non-willful violations.

...Ming was a non-participating/non-contracting provider and the policy provided that if an insured received services from such a health care provider the insurer would pay benefits directly to the insured even if the insured assigned his benefits to such a non-participating/non-contracting health care provider. . Section 627.613, Florida Statutes, effective June 14, 1990, but not applicable to this case, appears to legislate a time for payment of claims by health insurers.