UNITED AUTOMOBILE INSURANCE COMPANY v. CENTRAL THERAPY CENTER, INC., A/A/O VANESSA LOPEZ

Citation: Not availableDocket: 21-0950

Court: District Court of Appeal of Florida; July 6, 2022; Florida; State Appellate Court

Original Court Document: View Document

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The Third District Court of Appeal of Florida issued an opinion on July 6, 2022, affirming the trial court’s summary judgment in favor of Central Therapy Center, Inc., as the assignee of Vanessa Lopez, against United Automobile Insurance Company. The case involves Florida's "No-Fault Personal Injury Protection" (PIP) statute, specifically sections 627.730 et seq. United Automobile had appealed the trial court's decision, which found that despite the insurer conceding that the physiotherapy treatments were medically reasonable and necessary, it could not refuse payment based on alleged non-compliance with record-keeping requirements for chiropractors.

The facts indicate that Lopez was injured in a car accident and assigned her reimbursement rights to Central Therapy, which subsequently sued United Automobile for payment. Although United Automobile acknowledged the treatments' necessity, it argued that the medical records did not comply with statutory record-keeping requirements. The disputed records included brief, unclear comments on a pre-printed form listing the treatments.

The trial court concluded that the medical records complied with applicable statutes and that technical noncompliance did not invalidate the treatments under the law. The appellate court's analysis emphasized the requirement that insurers reimburse only for lawful, reasonable, and medically necessary care, confirming the lower court's ruling that compliance with record-keeping requirements is not a basis for denying payment when medical necessity is established. The summary judgment was thus affirmed, with the court reviewing the decision de novo.

Caselaw interprets the relevant statutes to require that services must be connected to the accident for which coverage is sought, as established in *United Auto. Ins. Co. v. W. Med. Ctr. Health Care II, Corp.*, 326 So. 3d 794, 795 n.2 (Fla. 3d DCA 2021). Additionally, under Florida Statute 627.736(5)(b)(1)(b), insurers are not obligated to pay for any services or treatments that were unlawful at the time they were provided. "Lawful" is defined as substantial compliance with all applicable state and federal laws related to medical services, per Florida Statute 627.732(11). 

United Auto argues that Lopez's physiotherapy treatments were unlawful due to non-compliance with medical record standards outlined in section 460.413(1)(m) of the Florida Statutes and Florida Administrative Code Rule 64B2-17.0065. Section 460.413 establishes grounds for disciplinary action against chiropractors, including failure to maintain adequate medical records that clearly identify the licensed chiropractor and justify the treatment provided. 

Rule 64B2-17.0065 sets forth minimal recordkeeping standards for licensed chiropractic physicians and assistants, emphasizing the necessity of maintaining comprehensive medical records for patient care, continuity, and legal protection. Medical records must include patient histories, examination results, treatment justifications, and must be legibly maintained. If abbreviations are used, a key must be provided to ensure clarity.

All patient records must include specific elements: patient history, symptomatology or wellness care, examination findings (including X-rays if necessary), diagnosis, prognosis, assessments, treatment plans, and treatments provided. Each entry in medical records must be accurately dated, with the treating physician identifiable by signature, initials, or printed name. Late entries are allowed but must be clearly marked and dated upon entry.

Once a treatment plan is established, daily records should document subjective complaints, objective findings, assessments, treatments provided, and periodic reassessments as needed. For medical examinations, tests, or treatments requested by third parties (such as employers or insurance companies), physicians must maintain appropriate medical records as per Section 456.057, F.S. However, these requirements do not apply when actions are taken under a court order or as part of an independent medical examination. Destruction of medical records is only permitted as allowed by law or rule.

In cases where the Board disciplines a chiropractic physician, these minimal clinical standards will apply, recognized as the accepted standards under the relevant chapter. The argument by United Automobile that non-compliance with recordkeeping makes related medical services unlawful is rejected. The lawfulness requirement in section 627.736(5)(b)(1)(b) focuses on the services or treatments themselves, not merely on recordkeeping compliance. Failure to adhere to recordkeeping standards is grounds for disciplinary action under section 460.413 but does not render the treatments illegal. The interpretation and enforcement of these provisions are left to the expertise of the Board and Department, which may impose sanctions for violations.

Rule 64B2-17.0065 mandates that minimal clinical standards apply when the Board takes disciplinary action against a chiropractic physician. The United Automobile case challenges this legislative framework by suggesting insurers and courts should assess medical records—such as the legibility of doctors' notes—to determine compliance with the rule's requirements. This approach diverges from the Legislature's intent to focus on the legality of the treatment or service itself, as established in section 627.736(5)(b)(1)(b). The case references Gallo Med. Ctr. v. State Farm Fire and Cas. Co. for insights on when an affirmative defense is closely tied to the lawfulness requirement. Furthermore, the statutory framework assumes that a provider will make their records available to insurers upon request, as outlined in section 627.736(6)(b). In this instance, the condition of the medical records does not hinder the insurer's ability to evaluate the reasonableness, relation, medical necessity, or legality of the services and treatment provided. The decision was affirmed on March 26, 2019, by Judge Bokor, who supported the validity of an “unlawfulness” affirmative defense that specifically addresses the legality of the service in question.