`
`
`CLERK8/1/20131:37:17PM.****
`
`
`
`***FILED:BROWARDCOUNTY,FLHOWARDFORMAN,
`
`Case Number: COCE-13-014202 Division: 50
`Electronically Filed 08/01/2013 01:37:18 PM ET
`
`IN THE COUNTY COURT OF THE
`SEVENTEENTH JUDICIAL CIRCUIT IN AND
`FOR BROWARD COUNTY,FLORIDA
`
`HOLLYWOOD DIAGNOSTICS CENTER, INC
`(a/afo LUDIE RIMPEL)
`
`CASE NO.:
`
`Plaintiff,
`
`vs.
`
`ALLSTATE
`INSURANCE COMPANY
`
`Defendant.
`
`/
`
`COMPLAINT FOR DAMAGES AND DEMAND FOR JURY TRIAL
`
`Plaintiff, HOLLYWOOD DIAGNOSTICS CENTER, INC (A/A/O LUDIE RIMPEL)
`
`(“Plaintiff”) sues Defendant ALLSTATE INSURANCE COMPANY(“Defendant”or “Insurer”)
`
`and alleges as follows:
`
`1,
`
`This is an action for damages in the principal amount of $971.58, exclusive of
`
`interest, penalties, costs, and attorneys’ fees, and is within the jurisdictional limits of this court.
`
`2,
`
`Atall times material hereto Plaintiff is and was a Florida business entity engaged
`
`and authorized to do business in Broward County, Florida.
`
`3.
`
`Atall times material hereto, Plaintiff is and was authorized to perform medical
`
`services in Broward County, Florida. Specifically, Plaintiff provides medical services to, among
`
`others, those who have been injured in automobile accidents.
`
`4,
`
`At all times material hereto, Insurer is and was a corporation engaged in and
`
`authorized to do business in Broward County, Florida.
`
`5.
`
`At all times material hereto, Insurer is and was authorized to enter into contracts
`
`providing automobile insurance coverage in the State of Florida.
`
`

`

`6.
`
`At all times material hereto, LUDIE RIMPEL(“Patient”) is and was a resident of
`
`the State of Florida.
`
`7.
`
`On or about May 31, 2012 Patient was injured in a vehicular collision (the
`
`Accident”).
`
`8.
`
`At the time of the Accident Patient was insured under a policy of automobile
`
`insurance naming Patient as insured and Insurer as insurer (the “Policy”). Defendant has
`
`assigned claim number 0247057300-7KA to this claim and has acknowledged receipt of the
`
`claim that is the subject of the instant case.
`
`9.
`
`The Policy provided Patient with personal injury protection benefits.
`
`10.
`
`On June 18, 2012 Patient sought and received medically necessary services from
`
`Plaintiff that were related to the Accident, and incurred reasonable medical expenses in the
`
`treatment of Patient’s injuries.
`
`11.
`
`The Plaintiff billed $2,400.00 for medical services rendered to the Patient. The
`
`Insurer paid $948.42. The amount due and owingto the Plaintiff is $971.58.
`
`12.
`
`Patient assigned its rights to personal injury protection benefits to Plaintiff via an
`
`assignment of benefits.
`
`13.
`
`Plaintiff made a claim under the Policy by submitting its reasonable bill
`
`to
`
`Defendant, but Defendant failed and refused to pay the amounts required by the Policy and
`
`Florida law.
`
`14.
`
`Specifically, Defendant breached the Policy by denying payment to the Plaintiff
`
`for medical services that were reasonable, necessary and related to the automobile accident in
`
`question. As a direct and proximate result of the breach, Plaintiff has suffered damages.
`
`

`

`15.
`
`Plaintiff has performed all conditions precedent prior to the institution of this
`
`cause of action.
`
`16.
`
`‘Plaintiff has been forced to retain the services of the undersigned law firm to
`
`prosecute this cause and has agreed to pay a reasonable fee for its services.
`
`17.
`
`Plaintiff is entitled to an award of attorney’s fees pursuant to Florida Statutes,
`
`Section 627.736(8).
`
`DEMAND FOR JURY TRIAL
`
`Plaintiff hereby demandsa trial by jury on all claims and issues sotriable.
`
`WHEREFORE,Plaintiff demands judgment for damages against Defendant, plus pre-
`
`judgment and post-judgmentinterest, all available penalties, costs, reasonable attorneys’ fees and
`
`such other and further relief as this Court deems just and proper.
`Dated this 10 day of July, 2013 in Hollywood, Florida.
`
`Respectfully submitted,
`
`Sean A. Storani, P.L.
`Attorneys for Plaintiff
`2004 Polk Street
`Hollywood, Florida 33020
`Telephone: (954) 923-8222
`Facsimile:
`(954) 927-0101
`
`By:
`
`/s/ Sean_A. Storani
`SEAN A. STORANI
`Florida Bar No. 011681
`
`

`

`
`
`79. RESERVED FOR LOCAL USE
`
`2
`
`C6 FG a2
`
`|
`
`.
`
`
`
`| 72131
`
`|
`
`tt
`
`a
`>
`
`*
`
`1500
`HEALTHINSURANCE CLAIM FORM
`RepROvED BY NATIONAL UNIFORM GLAIM COMMITTEE 08/08
`
`
`
`
`1.
`MEDICAID
`TRIGARE
`~ CHAMPVA
`GROUP. eLAM
`- OTHER]aJa.INSURECSLD. NUMBER
`“(For Program in =
`
`
`
`MEDICARE.
`(itaclionre2)(|(Medicaid £)(jeBponsor'sSSN}r|(vemberDK)[|(SSNorID) meprya |3|
`TH
`Mt
`9,PATIENT'SNAME(LastName,FirstName, Middle Infiiat
`3. PATENTSBIRTH Rae
`BEX sa2, INSURED'SNAME (Las!Name,FirstNama,Middle Jota
`
`RIMPEL, LODIE r[X]|RIMPEL, LuDrE —_- (Sir? 2973 Wl]
`
`
`
`5. PATIENT'S ADDRESS (No., Street)
`6. PATENT RELATIONSHIP TO INSURED
`| 7. INSURED'S ADDRESS (No., Streei)
`PO BOX 840023
`so] spouseTowel] otter] |
`PO BOX 840023
`
`
`ony
`STATE
`jcrry
`PEMBROKE PINES
`|
`F
`
`| SIATE §. PATIENT STATUS
`
`
`PEMBROKE PINES i Singie [| Maried|| other || | eb
`
`
`
`ZIP CODE
`‘TELEPHONE (Include Area Code}
`:
`{ZIP CODE
`TELEPHONE {Include Area Cade)
`
`33084 | employes{_]See?[|SANE] | 33084| (25496624797 { 95a) 6624797
`
`
`
`\
`Full-Time
`Part-Time!
`‘
`
`fe. OTHER INSURES NAME (Lasi Name, First Name, Middle tnitial}
`10. 1S PATIENT'S CONDITION RELATED TO:
`71, INSURED'S POLICY GROUP OF FECA NUMBER
`RIMPEL, LUDIE
`O8L212873
`
`a. OTHER INSURED'S POLICY OR GROUP NUMBER
`a. EMPLOYMENT? (Current or Previous}
`a. INSUREDSS Dave OF BIRTH
`SEX
`[]yves
`[ano
`O3 11a hors
`wf |
`FTX
`
`
`bh. OTHER INSURED"S DATE OF BIRTH
`SEX
`b. AUTO ACCIDENT?
`PLACE(State) 1b. EMPLOYER'S NAME OR SCHOOL NAME
`O83 114 1979 F[X][elvesf|e | EL|| «fj
`
`
`c. CMPLOYEAR’S NAME OR SCHOOL=Ee
`ce. OTHERACCIDENT?
`lc. INSURANCE PLAN NAME OR PROGRAM NAME
`
`P|ves—[ano
`ALLSTATE
`d. IS THERE ANOTHER HEALTH SENGEIT PLAN?
`d. (INSURANCE PLAN NAME GR PROGRAM NAME
`(tad. RESERVED FOR LOCAL USE
`
`i x] ves
`| NO
`ifyes, retum to and complete item 9 a-d,
`[ROSENBERG AND ROSENBERG
`READ BACK OF FORM BEFORE COnPLETING & SIGNING THIS FORK.
`13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE| authorize
`12. PATIENT'S OF AUTHORIZED PERSON'S SIGNATURE | authorize the release of any medical or otherinformation necessary
`
`payment of medical benetits fo the undersigned physician or supplier tor
`services described below.
`to process this claim,| also request payment of gevernment genefits either to myself or to de party who accepts assignment
`pew.
`SIGNATURE ON FILE
`06/18/12
`|_SIGNED
`DATE
`SIGNED
`
`|4
`
`
`15.IF PATIENT HAS HAD SAME OR SIMMICARILLNESS.
`14. DATE ofGURRERT:
`ILLNESS (First symptom) OR
`
`GIVE FIRST DATE
`BD
`NJURY (Accident)
`|
`!
`) OD Y
`co i3 r°2 o1Z
`FROM
`PREGNANCYLMP): NJURY
`|
`|
`|
`TO
`
`17. NAME OF REFERRING PROVIDER OR OTHER SOURCE va)
`Ve. HOSPITALIZATION DATESRELATED TO CURRENTSERVICES
`OS
`--~}-~4 ~~2-Hi
`1
`MM
`|
`J
`7b.) NPI |
`793237 9655
`RONALD GOLDEN DC
`FROM ||
`To
`
`20. OUTSIDE LAB?
`$ CHARGES
`[" Ives
`[Xt xo
`|
`24, DIAGNOSIS OR NATURE OF ILLNESS OF INJURY (Fielate tems 1, 2, 3 of 410 item 245 by Line)
`BE. MEDICAID RESUBMISSION
`45
`DE
`GRIGINAL REF, NO.
`1. Li23 nn
`oo
`3, LU
`i
`I
`
`{23 PRIOR AUTHORIZATION NUMBER
`7 a
`24
`2
`F,
`E.
`D. an:SERVICES, ORSUPPLIES
`DATE(S) OFSERVICE
`Vea. A.
`
`DAGNOSIS|
`{Explain Unusual Circurnstances)
`From
`( po
`YY
`MM
`Do
`
`ae EMG|CPT/HOPCS =} MODIFIER POINTER j $ CHARGES
`
`
`
`
`Oe |W ne|OoOR 22 | 14) jf 72125 ff ot ta {| 1200) 00
`
`
`
`
`
`
`
`
`|
`\
`|
`1
`|
`|
`'
`|
`t
`I
`i
`\
`
`! por
`ee ee
`!
`1
`I
`|
`'
`1
`'
`'
`|
`ee ee po est
`i
`1
`i
`J
`i
`1
`i
`\
`4
`r
`1
`i
`dt
`|
`jot | | eee
`, ;
`
`30. BALANCEDUE
`25. FEDERALTAXLD. NUMBER
`SSN EIN
`25. PATIENT'SACCOUNTNO.
`oF,foraLASSIGNMENT?
`28.TOTALCHARGE
`25. AMOUNTPAID
`
`
`
`
`
`
`
`592440695 es|Ino[jf] RIMLUOGO 151669 $ 2400100] 8 1 18 2400100
`
`
`
`
`
`
`Sw Int TAR ™ c
`( 95439663600teu
`INCLUDING.BEGREES, SOR CREDENTIAL! 31. SIGNATURE OF PHYSICIAN-OR SUPPLIER, | 32. SERVICE FACILITY LOCATION INFORMATION
`
`138. BILLING PROVIDER INFO & PH 4
`
`x
`
`
`
`
`
`pEFWOOD DIAGNOSTICS CENTER
`(I cenity thatina.Stateméuts
`on thesavethe
`HO DIAGNOSTICSCENTER
`
`
`nace2 pathee
`4224 HOLLYWOOD BLVD
`apply to this bill and af
`HOLLYWOOB BLVD
`
`
`HOLLYWOOD FL 33021-6635
`HOLLYWOOD FL 33021-6633
`
`
`
`
`\
`
`ALLSTATE
`
`PO BOX 440519
`KENNESAW GA 30260-9509
`
`4
`VF)
`
`j
`
`SIGNATURE ON FILE
`
`} |i
`
`!It
`
`PATIENTANDINSUREDINFORMATION=
`
`
`
` PHYSICIANORSUPPLIERINFORMATION
`
`
`
`
`€
`

`

`HOLLYWOOD DIAGNOSTICS CENTER
`4224 Hollywood Boulevard, Hollywood, Florida 33021
`(954) 966-3600 Ext. 305 Fax (954)967-1962
`ASSIGNMENTOF INSURANCEBENEFITS, POWER OF ATTORNEYAND REALS#H OFINFORMATIONInsurer Please Read
`the Foliowing,in its Entirety, upon Receipt:
`
`1, the undersigned patient/insured knowingly, voluntarily and intentionally assign any and all insurance benefits to the above medical
`provider. This assigument of benefits includes over due interest payments and any potential claim for bad faith. | understanditis the
`express intention ofthe providerto accept this assignmentof benefits in liew of demanding paymentat the timeservices are rendered. If
`the insurer disputes the validity ofthis assignment of benefits then the insureris instructed to notify the provider in writing within (5)
`days of receipt of this document. Failure io inform the provider shall result in a waiver by the insurer to contest the validity ofthis
`document. The undersigned directs the insurer to pay the medical provider directly without including the patient’s name on the check.
`
`~
`
`The insureris directed by the provider and ihe undersigned to not issue any checks or draits in partial settlement of a claim that contain
`or are accompanied by languagereleasing the insurerorits insured/patient form liability unless there has been a prior written settlement
`agreed to by the medical provider and the insurer as to the amount payabic under the surance policy or contact. The provider hereby
`objects to any reductions or partial payments. Any partial or reduced payment, regardless ofthe accompanying language, issued by the
`insurer and deposited by the provider shall be done so underprotest, at the sk of the insurer, and the deposit shal] not be deemed a
`wavier, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as paymentin full. The
`insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted,
`
`'
`
`In the event the subject medica] benefits are disputed by the insurer for any reason the undersigned hereby instructs the insurerto set
`aside any amount disputed (i.e. to escrow the money) and not pay the disputed amount to anyone, including myself, or any entity until
`the dispute is resolved. The insureris instructed to immediately explain in writing to the above provider of any dispute. If the insurer
`schedules a defense examination or examination under oath (herein after “EUO”) the insurer is hereby INSTRUCTEDto send a copy of
`said notification to this provider. The provider is authorized to appear at aay EUO set by the insurer. The medical provideris not the
`agent of the insurer orthe patient.
`
`I understand this assignment will remain in full force and effect and will not be revoked unless the revocation is agreed to by both the
`medical provider and the undersigned or the undersigned’s attorney. This assignment applies to both past and future medical expenses
`and is valid even if undated. A photocopy of this assignmentis to considered as valid as the original.
`
`I agree to pay any applicable deductible, co-payments, for services rendered after the policy of Insurance exhausts, and for any other
`services unrelated to the automobile accident.
`
`Power of attorney: The above medical provider is hereby given the power of attorney by the undersigned to sign my name on any checks
`for payment for services rendered by the above provider.
`
`Release of information: I hereby authorize this medical provider to: fiumish the insurer and the patient’s attomey with any andall
`information that may be contained in the medical records; to obtain coverage information telephonically ftom the insurer; to request all
`EOBsand non-redacted PIP payout sheets from the insurer; and to obtain 2 copies of all medical records, including but not limited, to
`documents, reports, scans, notes, opinions, Xrays, and MRIs, form any other medical provider or any insurer. The insurer is directed to
`keep the patient’s medical records private and confidential. The insurer is NOT authorized to provide these medical records to anyone,
`including butnot limited to, third party vendors without the patient’s and the provider’s express written permission.
`
`T certify that I have not been solicited or promised anything in exchange for receiving medical care or that I have received any promises
`Or puarantees from anyone as to the results that may be obtained by any medicaltreatment.
`Caution! Please read before signing. If you do not completely understand this document please ask us to explain it-to you. If you sign
`
`belowwewillassumeyor’Sodyeagreetotheterm! (Ifpatient is a minor, signature ofparent/euiardian)
`
`