Court Opinion

ID: 6498121
Source: CourtListenerOpinion
Date Created: 2022-07-06 16:01:52.378871+00
Date Added: 2024-06-11T08:50:43.048928
License: Public Domain

Third District Court of Appeal
                               State of Florida

                          Opinion filed July 6, 2022.
       Not final until disposition of timely filed motion for rehearing.

                            ________________

                             No. 3D21-950
                      Lower Tribunal No. 13-474 CC
                          ________________

            United Automobile Insurance Company,
                                  Appellant,

                                     vs.

      Central Therapy Center, Inc., a/a/o Vanessa Lopez,
                                  Appellee.

    An Appeal from the County Court for Miami-Dade County, Gloria
Gonzalez-Meyer, Judge.

     Michael J. Neimand, for appellant.

     David B. Pakula, P.A., and David B. Pakula (Pembroke Pines);
Corredor & Husseini, P.A., and Maria E. Corredor, for appellee.

Before LOGUE, LOBREE, and BOKOR, JJ.

     LOGUE, J.
      This case arises under Florida’s “No-Fault Personal Injury Protection”

insurance laws, commonly known as the “PIP” statute, sections 627.730 et

seq., Florida Statutes. United Automobile Insurance Company appeals the

trial court’s order granting final summary judgment in favor of Central

Therapy Center, Inc. as the assignee of Vanessa Lopez. The issue is

whether an insurer that concedes physiotherapy treatments were medically

reasonable and necessary can refuse to pay for the treatments because the

records maintained by the treating physician failed to comply with the record-

keeping requirements of the laws and regulations governing the licensing of

chiropractors. We hold that, where an insurer agrees treatments are

medically reasonable and necessary, a failure to comply with the record

keeping requirements governing the licensing of chiropractors is not a basis

to refuse to compensate the claim. Accordingly, we affirm.

                                   FACTS

      Ms. Lopez was injured in a car accident. She received medical

treatments from, and assigned her right to be reimbursed for the cost of the

treatments to, Central Therapy. Central Therapy sued United Automobile for

reimbursement. In the course of the lawsuit, United Automobile stipulated

that the physical therapy treatments Central Therapy provided to Ms. Lopez

were reasonable and necessary. Nevertheless, United Automobile

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contended that Lopez’s medical records failed to comply with the statutes

and regulations governing the record-keeping requirements of chiropractors.

      The medical records in their entirety consist of approximately 100

pages, including the diagnoses and treatment plans made over four visits in

the course of eight weeks. The record in controversy was made on a pre-

printed form. The section of the record in dispute lists 12 physical therapy

treatments with the language “(1-2)” next to them and a line for a check mark.

Rather than individually check each of the therapies, the chiropractor drew

a bracket including all of them and made a nine-word illegible comment,

which she initialed.

      The trial court granted summary judgment in favor of Central Therapy.

It determined both that (1) an examination of the medical record itself

indicated that there was no factual dispute and the record complied with the

applicable statutes and regulations; and (2) technical noncompliance with

the record keeping requirements in these circumstances did not render the

treatments “unlawful” under the statute. United Automobile timely appealed.

                                 ANALYSIS

      We review a trial court’s order granting final summary judgment de

novo. Volusia County v. Aberdeen at Ormond Beach, L.P., 760 So. 2d 126

(Fla. 2000).

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      We focus on the trial court’s second ground for granting summary

judgment. The dispute on this ground centers on the provisions of the PIP

laws that require the insurer to reimburse only covered lawful medical care

that is reasonable, related, and medically necessary. § 627.736(1)(a)

(requiring that all automobile insurance contracts provide coverage for

“[e]ighty percent of all reasonable expenses for medically necessary medical

. . . and rehabilitative services.” (emphasis added)). The caselaw has

interpreted this language as requiring that the services be related to the

accident giving rise to coverage. See United Auto. Ins. Co. v. W. Med. Ctr.

Health Care II, Corp., 326 So. 3d 794, 795 n.2 (Fla. 3d DCA 2021). Another

provision of the PIP statutes provides “[a]n insurer or insured is not required

to pay a claim or charges . . . [f]or any service or treatment that was not lawful

at the time rendered.” § 627.736(5)(b)(1)(b), Fla. Stat. (emphasis added). As

defined in the statute, “‘Lawful’ or ‘lawfully’ means in substantial compliance

with all relevant applicable criminal, civil, and administrative requirements of

state and federal law related to the provision of medical services or

treatment.” § 627.732(11), Fla. Stat.

      United Auto contends that Lopez’s physiotherapy treatments were

unlawful because the prescription for the treatment failed to comply with

standards for medical records in accordance with section 460.413(1)(m),

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Florida Statutes, and Florida Administrative Code Rule 64B2-17.0065.

Section 460.413 is entitled “Grounds for disciplinary action; action by board

or department.” It provides that a chiropractor is subject to disciplinary action

for various reasons including failure to maintain records to certain standards.

It reads:

             (1) The following acts constitute grounds for denial of
             a license or disciplinary action, as specified in s.
             456.072(2):
             ...
             (m) Failing to keep legibly written chiropractic
             medical records that identify clearly by name and
             credentials the licensed chiropractic physician
             rendering, ordering, supervising, or billing for each
             examination or treatment procedure and that justify
             the course of treatment of the patient, including, but
             not limited to, patient histories, examination results,
             test results, X rays, and diagnosis of a disease,
             condition, or injury. X rays need not be retained for
             more than 4 years.

§ 460.413, Fla. Stat. Regarding this statutory record-keeping requirement,

the Florida Department of Health, Division of Chiropractic Medicine,

promulgated Rule 64B2-17.0065 further clarifying the recordkeeping

standards:

             Minimal Recordkeeping Standards.
             (1) These standards apply to all licensed chiropractic
             physicians and certified chiropractic assistants.
             These standards also apply to those examinations
             advertised at a reduced fee, or free (no charge)
             service.

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(2) Medical records are maintained for the following
purposes:
(a) To serve as a basis for planning patient care and
for continuity in the evaluation of the patient’s
condition and treatment.
(b) To furnish documentary evidence of the course of
the patient’s medical evaluation, treatment, and
change in condition.
(c) To document communication between the
practitioner responsible for the patient and any other
health care professional who contributes to the
patient’s care.
(d) To assist in protecting the legal interest of the
patient, the hospital, and the practitioner responsible
for the patient.
(3) The medical record shall be legibly maintained
and shall contain sufficient information to identify the
patient, support the diagnosis, justify the treatment
and document the course and results of treatment
accurately, by including, at a minimum, patient
histories; examination results; test results; records of
drugs dispensed or administered; reports of
consultations and hospitalizations; and copies of
records or reports or other documentation obtained
from other health care practitioners at the request of
the physician and relied upon by the physician in
determining the appropriate treatment of the patient.
Initial and follow-up services (daily records) shall
consist of documentation to justify care. If
abbreviations or symbols are used in the daily
recordkeeping, a key must be provided.
(4) All patient records shall include:
(a) Patient history;
(b) Symptomatology and/or wellness care;
(c) Examination finding(s), including X-rays when
medically or clinically indicated;
(d) Diagnosis;
(e) Prognosis;
(f) Assessment(s);
(g) Treatment plan; and,

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          (h) Treatment(s) provided.
          (5) All entries made into the medical records shall be
          accurately dated. The treating physician must be
          readily identifiable either by signature, initials, or
          printed name on the record. Late entries are
          permitted, but must be clearly and accurately noted
          as late entries and dated accurately when they are
          entered into the record.
          (6) Once a treatment plan is established, daily
          records shall include:
          (a) Subjective complaint(s);
          (b) Objective finding(s);
          (c) Assessment(s);
          (d) Treatment(s) provided; and,
          (e) Periodic reassessments as indicated.
          (7) In situations involving medical examinations,
          tests, procedures, or treatments requested by an
          employer, an insurance company, or another third
          party, appropriate medical records shall be
          maintained by the physician and shall be subject to
          Section 456.057, F.S. However, when such
          examinations, tests, procedures, or treatments are
          pursuant to a court order or rule or are conducted as
          part of an independent medical examination
          pursuant to Section 440.13 or 627.736(7), F.S., the
          record maintenance requirements of Section
          456.057, F.S., and this rule do not apply. Nothing
          herein shall be interpreted to permit the destruction
          of medical records that have been made pursuant to
          any examination, test, procedure, or treatment
          except as permitted by law or rule.
          (8) Provided the Board takes disciplinary action
          against a chiropractic physician for any reason, these
          minimal clinical standards will apply. It is understood
          that these procedures are the accepted standard(s)
          under this chapter.

Fla. Admin. Code R. 64B2-17.0065.

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      We are not persuaded by United Automobile’s argument that a treating

physician’s failure to comply with the recordkeeping provisions of section

460.413 and rule 64B2-17.0065 makes an otherwise reasonable, related,

and medically necessary service or treatment “unlawful” as that term is used

in section 627.736(5)(b)(1)(b). The focus of 627.736(5)(b)(1)(b)’s lawfulness

requirement is on “service or treatment.” It provides an insurer need not pay

for “service or treatment” that is unlawful. When read in the context of the

PIP statutes as a whole, we believe this language is concerned with whether

the service or treatment itself violates existing laws.

      The recordkeeping provisions that United Automobile cites, however,

do not deal with the lawfulness of services or treatments. Instead, they deal

only with the recordkeeping that a chiropractor must maintain to keep his or

her license in good standing. Section 460.413 is entitled “Grounds for

disciplinary action, action by board or department.” The statute provides that

failure to abide by its provision constitutes grounds for disciplinary action, “as

specified in § 456.072(2).” This language contrasts with other parts of

Chapter 460 that make certain conduct illegal. See, e.g., § 460.411(1)(a)

(making practice of chiropractic medicine without a license a third-degree

felony). Thus, there is no indication that the Legislature intended that a failure

                                        8
to maintain records to the standard in the regulations would render the

treatment or service itself per se illegal.

      Moreover, section 456.072(2) leaves the interpretation and application

of these provisions, certainly in the first instance, to the expertise of the board

and department. It specifically states that “[w]hen the board, or the

department when there is no board, finds any person guilty” of an action

justifying a disciplinary response it may enter an order imposing one of

several sanctions. Likewise, rule 64B2-17.0065 indicates that “[p]rovided the

Board takes disciplinary action against a chiropractic physician for any

reason, these minimal clinical standards will apply.” United Automobile

would upend this legislative assignment of responsibility and place insurers

and courts in the role of combing through records to decide when, for

example, the occurrence of illegible notes by doctors failed to substantially

comply with the requirement that “[t]he medical record shall be legibly

maintained” established in rule 64B2-17.0065(3). That analysis is too far

removed from the focus on the legality of the treatment or service itself which

was the Legislature’s concern in the lawfulness requirement of section

627.736(5)(b)(1)(b). 1

1
  For a thoughtful analysis on when an affirmative defense is more directly
related to the lawfulness requirement of the statute, see Gallo Med.Ctr. v.
State Farm Fire and Cas. Co., 27 Fla. L. Weekly Supp. 130b (Fla. 11th Cir.

                                        9
      At the same time, we acknowledge that the statutory framework

presumes that a provider’s records will be made available to a covering

insurer. See § 627.736(6)(b) (providing that upon request a provider must

“furnish a written report of the history, condition, treatment, dates, and costs

of such treatment of the injured person”). In this case, we are not dealing

with a situation where the condition of the medical records prevents the

insurer from evaluating whether the service and treatment were reasonable,

related, medically necessary, or lawful.

      Affirmed.

Mar. 26, 2019) (Bokor, J.) (permitting an “unlawfulness” affirmative defense
that addresses specifically the legality of the provision of the service at
issue).

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