Filing # 79645372 E-Filed 10/22/2018 10:59:03 AM
`
`IN THE COUNTY COURT IN AND
`FOR ORANGE COUNTY, FLORIDA
`
`CASE NO.:
`
`BOWES IMAGING CENTER, LLC
`
`a/a/o Ashley Crow
`
`Plaintiff,
`
`VS.
`
`PEACHTREE CASUALTY
`INSURANCE COMPANY
`
`Defendant
`
`/
`
`COMPLAINT
`
`COMES NOW, Plaintiff, BOWES IMAGING CENTER, LLC a/a/o Ashley
`Crow (hereinafter "Plaintiff) sues the Defendant, PEACHTREE CASUALTY
`INSURANCE COMPANY (hereinafter "Defendant"), and in support
`thereof
`alleges the following:
`
`GENERAL ALLEGATIONS
`
`This is an action for Breach of Contract for damages in excess of Five
`1.
`Thousand Dollars ($5,000.00) but does not exceed Fifteen Thousand Dollars
`($15,000.00) exclusive of interest, costs and attorney's fees and is within the
`jurisdictional limits of this Court.
`
`Defendant was and remains a corporation organized and existing
`2.
`under the laws of the State of Florida and is otherwise sui juris.
`
`Defendant was and is a corporation authorized to do business,
`3.
`maintains an office and agents in ORANGE COUNTY and regularly sells
`automobile insurance policies to the general public in ORANGE COUNTY. The
`Defendant and/or its affiliates and/or its subsidiaries which issued the policy of
`insurance have substantial identities of interest.
`
`At all times material hereto, Plaintiff was a corporation duly licensed
`4.
`to perform medical services in the State of Florida.
`
`[1529-01244/7894823/1]
`
`

`

`On or about March 30, 2015, Ashley Crow (hereinafter "Claimant")
`5.
`was involved in a motor vehicle accident.
`
`As a result of that motor vehicle accident, Plaintiff provided Claimant
`6.
`with medical services and/or treatment.
`
`As a direct and proximate result of the injuries sustained by Claimant
`7.
`in the accident, Claimant incurred reasonable expenses for necessary medical and
`rehabilitative care by the Plaintiff for an Emergency Medical Condition as
`evidenced by the Claimant's entire medical record. To date, Defendant refuses to
`pay the full amount due.
`
`issued a policy of insurance to Ashley Crow which
`Defendant
`8.
`provided personal injury protection benefits coverage required by law to comply
`with Florida Statutes Sections 627.730 thru 627.7405. Plaintiff does not have a
`copy of the policy to attach; however, Plaintiff believes that the Defendant has a
`copy of said policy. Upon receipt of a certified copy of the insurance policy, same
`is hereby attached and incorporated herein by reference.
`
`The above described policy was in full force and effect on the date of
`9.
`the accident and provided PIP coverage for Ashley Crow for bodily injuries
`sustained in said accident.
`
`Plaintiff and Claimant have performed the statutorily required
`10.
`conditions precedent
`to entitle Plaintiff to recover benefits for said necessary
`regarding the above-described
`medical,
`rehabilitative and remedial
`treatment
`policy and statutory conditions precedent to instituting this action.
`
`Claimant equitably assigned to Plaintiff and/or also executed a written
`11.
`assignment of benefits, assigning to Plaintiff certain benefits payable pursuant to
`the policy of insurance issued by Defendant.
`
`to said Assignment, Plaintiff gave notice of the covered
`12
`Pursuant
`losses and Plaintiff made demand for PIP benefits for reasonable, necessary and
`related medical treatment.
`
`Defendant has denied coverage for, withheld or reduced the medical
`13.
`bill(s) that were submitted by Plaintiff for date(s) of service June 25, 2015 and/or
`misapplied the application of
`the deductible. Furthermore, Defendant was
`precluded from applying a deductible at all because the nonexistence of a properly
`
`[1529-01244/7894823/1]
`
`

`

`executed deductible election form. A copy of the HCFA bills and/or patient ledger
`and/or explanation of benefits/review are attached hereto and incorporated by
`reference. Due to the failure of Defendant to pay these PIP benefits in accordance
`with the law, Plaintiff has been required to retain the undersigned law firm to act
`on their behalf in this suit. Plaintiff has agreed to pay, and the attorneys for
`Plaintiff have agreed to accept, any court awarded fee.
`
`BREACH OF CONTRACT FOR FAILURE TO PAY AMOUNTS OWED.
`
`14.
`complaint.
`
`Plaintiff reavers and realleges paragraphs 1
`
`through 13 of this
`
`Despite prior demand by Plaintiff, Defendant has refused and
`15.
`continues to refuse to issue payment of all sums due Plaintiff,
`in violation of
`Section 627.736, Florida Statutes, and in breach of its contact with claimant.
`
`Plaintiff has retained the undersigned firms to represent
`16.
`action and has agreed to pay a reasonable fee for said services.
`
`it in this
`
`Pursuant to Section 627.428, Florida Statutes, Plaintiff is entitled to
`17.
`recover from Defendant reasonable attorney's fees and costs for the necessity of
`this action.
`
`WHEREFORE, Plaintiff requests:
`
`a.
`
`b.
`
`c.
`
`d.
`
`e.
`
`this Honorable Court declare that Defendant
`That
`payment of all sums due to Plaintiff;
`
`is overdue in
`
`That Defendant pay all sums due to Plaintiff under Claimant's policy
`of Insurance with Defendant;
`
`That Defendant pay interest on all unpaid sums in accordance with
`Section 627.736(4), Florida Statutes;
`
`That Defendant pay Plaintiffpre-suit penalty, postage, and interest in
`accordance with Section 627.736(10), Florida Statutes.
`That the Defendant correctly apply the deductible "to 100 percent of
`the expenses and losses" as described in Fla. Stat. 627.736, if
`applicable;
`
`[1529-01244/7894823/1]
`
`

`

`f.
`
`g.
`
`h.
`
`That The Defendants pay all sums due to Plaintiff under any medical
`payment's (med-pay) coverage's in accordance with the
`Claimant's/policy holder's policy of Insurance with Defendant;
`That Defendant pay Plaintiff reasonable attorney's fees and costs
`pursuant to Sections 627.428, Florida Statutes, and/or 627.736(5),
`Florida Statutes, for the necessity of this action;
`Any other relief this Court deems just and appropriate.
`
`injury
`for personal
`WHEREFORE, Plaintiff demands judgment
`protection benefits together with pre-judgment interest, costs and attorneysfees
`pursuant to Florida Statute 627.428 and Florida Statute sections 627.736(5) and
`(8) and any other relief this Court deems proper andjust.
`
`Plaintiff demands trial byjury on all issues triable as ofright.
`
`LANDAU & ASSOCIATES, P.A.
`1250 East Hallandale Beach Boulevard
`Suite 304
`Hallandale Beach, FL 33009
`Telephone (954) 744-8383
`Facsimile (954) 391-7805
`Email: efilings@pip-lawyers.com
`
`By:
`
`/s/Gregory E. Gudin
`GREGORY E. GUDIN, ESQ.
`Florida Bar # 14347
`
`[1529-01244/7894823/1]
`
`

`

`Bowes Imaging Center LLC
`
`ASHLEY CROW
`153563
`in Consideration of the treatment to be rendered to the patient by Bowes imaging Center LLC, I agree and consent to the following
`conditions:
`
`(1) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTHCARE
`OPERATIONS: The undersigned agrees that air records concerning this patient's treatment shall remain the property of Bowes
`imaging Center. The undersigned understands and agrees that such information is used for (i) the provision and coordination of the
`patient's health care which may require disclosure of ail or any portion of the patients medical record information to patients attending
`physician, consulting physicians and other health care providers who have a legitimate need for such information in the care and
`continuing treatment of the patient; (ii) billing, claims management, medical data processing, reimbursement and for determining
`coverage which may necessitate disclosure of such information to any insurance cornpany, third party payer or other entity (or their
`authorized representatives) including copies or excerpts the patients medical records which are necessary for payment of the patients
`account: (iii) routine heal(hcare opefations. Mcluding quality assurance, utilization review, risk management, medical peer review,
`internal auditing, accreditation, certification, Ncensing or credentialing activities of Bowes imaging Center LLC; and fly) medical
`research, legal and educational purposes.
`
`further authorize any hospital, physician or any health care provider who has attended me or furnished medical services, to disclose
`when requested to do so, all copies of all hospital or medical records to Bowes frnaging Center LLC.
`The information released may indicate the presence of a communicable or venereal disease, which may include, but is not limited to,
`diseases such as Hepatitis, Syphilis, Gonorrhea and infection with the Human Immunodeficiency Virus.
`l understand that l may revoke at any time except to the extent that action has already been taken in reliance hereon and if not
`revoked sooner in writing.
`l understand that have the right to examine and copy the information to be disclosed, unless deemed that
`such disclosure is not in my best interest.
`
`(2) PAYMENT RESPONSIBILITY: The undersigned understands that the patient, or another person who specifically agrees to
`guarantee payment for the patient, is responsible far the payment of elf charges for services rendered at Bowes tmaging Center LLC to
`the patient that exceed any third party coverage, including applicable coinsurance payments and deductibles and all amount for which
`payment has been denied by any third party, which amounts shall be due within ten (10) days of the statement date. The patient or
`guarantor shall pay all costs of collection in connection with the enforcement of this commitment, including reasonable attorneys fees
`and court costs incurred by Bowes Imaging Center LLC.
`f understand that if the Imaging services provided today is the result of an accident or other form of personal
`referred by an attorney, l am personally responsible for the payment of charges.
`(3) ASSIGNMENT OF BENEFITS: The patient hereby makes the assignment cif benefits as set forth below.
`
`injury and have been
`
`The patient hereby requests that payment of authorized Medicare benefits to or on behalf of the patient for services
`furnished by Bowes Imaging Center LLC shalt be made to Bowes imaging Center LLC and the patient specifically assigns such
`benefits to Bowes imaging Center LLC. The undersigned certifies that all information given by the patient in connection with applying
`for benefits under Title xyill of the
`Act is true, correct, and complete in all respects and permits a copy of this
`authorization to be used in place of the original.
`OTHER THIRD PARTY PAYORS: The patient hereby assigns to Bowes Imaging Center LLC benefits under any insurance policy,
`health plan, workerscompensation or other third party payer liable to the patient, in consideration for services renderer! by Bowes
`imaging Center LLC_ In the event my insurance company, including automobile insuranee companies and No-Fault insurers, fail to
`make payments for me for charges and services by this provider, l hereby assign and transfer to this provider, any and all causes ef
`action that l might have or that exist in my favor, against such company and authorize this provider to prosecute said cause of action
`in the their name as assignee. l further l authorize this provider to compromise, settle, or otherwise resolve said clairn or cause of
`action as they see fit. To avoid exhaustion of No Fault benefits while this provider pursues its right under this assignment, I authorize
`and direct my insurance company to set aside and place in escrow any disputed amounts or reductions until the resolution of such
`dispute.
`V7,4
`Patient or Parent/Legal Guardian Signature:
`(signature of parent/legal guardian is REQUIRED if 1šatlent is under 13 years of age)
`Patient or ParenVLegal Guardian Name (please print): 0-a1A-1
`Patient Name (Please;____1211-1
`
`C 0 J-1 ),Y
`1 ;LY)
`
`Date:
`
`Date!
`Date:
`
`Relationship to patient:
`
`Witness:
`
`0
`
`

`

`05/11/18
`Oper: CL1
`
`IRS #
`
`201226825
`
`Statement
`
`Page:
`
`1
`
`BOWES IMAGING CENTER
`DEPT 794 PO BOX 850001
`ORLANDO, FL 32885-0794
`Tel: 941 782 0490
`
`CROW, ASHLEY M
`220 WATERWAY CIR
`PORT CHARLOTTE,FL 33952
`
`/NF 595307361
`Pat: CROW, ASHLEY M 12/21/84
`Tel: 941/391-6348
`
`Ins1: PEACHTREE
`
`09624635
`
`Date
`
`Diag Ref C.P.T
`
`Qt Procedure
`
`AR P1 Pry Amt
`
`Bal
`
`06/25/15
`06/25/15
`
`06/25/15
`
`723.1 1437 72141
`
`724.1 1437 72146
`
`1 MRI CERVICAL W/0
`1 MRI THORACIC W/0
`
`NS 0
`
`NS 0
`
`BR
`
`BR
`
`2250.00
`
`2250.00
`
`724.2 1437 72148
`
`1 MRI LUMBAR W/0
`
`NS 0
`
`BR
`
`2250.00
`
`Referral Physician: NEW REFERRING DR
`
`Regular Balance:
`
`$
`
`6,750.00
`
`DOA 3-30-15
`Paid $0.00
`Balance $6,750.00
`
`