Filing # 193135581 E-Filed 03/01/2024 03:28:10 PM
`
`IN THE SMALL CLAIMS COURT OF THE
`NINTH JUDICIAL CIRCUIT IN AND
`FOR ORANGE COUNTY, FLORIDA
`CASE NO.: 2024-SC-1434-O
`
`BASIS MEDICAL, LLC A/A/O
`CHAVELA GRAHAM,
`
` Plaintiff,
`
`vs.
`
`SAFECO INSURANCE COMPANY OF ILLINOIS,
`
` Defendant.
`
`/
`
`RESPONSE TO REQUEST FOR ADMISSIONS
`
`Defendant, SAFECO INSURANCE COMPANY OF ILLINOIS, by and through the
`
`undersigned attorneys and in accordance with Florida Rule of Civil Procedure 1.370, hereby files
`
`this Response to Request for Admissions and states as follows:
`
`At all times material to the complaint, Defendant was and is a foreign corporation
`1.
`licensed to do business in the State of Florida and maintains agents in Orange County, Florida.
`RESPONSE: Defendant denies that it maintains agents in Orange County and objects to
`Plaintiff’s use of the term agents as it calls for legal conclusion. Subject to and without
`waiving said denial and objection, Defendant admits it was a corporation duly licensed and
`authorized to transact insurance in the State of Florida at all times material hereto.
`2.
`At the time of the accident referenced in the complaint, Chavela Gordon was insured
`under an automobile insurance policy issued by Defendant.
`RESPONSE: Defendant admits that a policy was issued; however, recovery is limited and
`subject to the terms and exclusions of the policy and Florida law.
`3.
`The automobile insurance policy that covered Chavela Gordon at the time of the accident
`referenced in the complaint provides coverage for PIP benefits for bodily injuries Chavela
`Gordon sustained as a result of the subject accident.
`RESPONSE: Defendant admits that a policy was issued; however, recovery is limited and
`subject to the terms and exclusions of the policy and Florida law. That policy affords
`Claimant $10,000 in PIP Benefits and carries a $1,000 deductible applicable to the Named
`Insured and relatives. Claimant is also a Named Insured. Defendant did not apply any
`portion of the deductible to Plaintiff’s bills.
`4.
`Defendant received all medical bills at issue in this case, as referenced in the complaint
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 1 of 8
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`

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`and/or attached exhibits, within the time required by Section 627.736(5)(c), Florida Statutes
`(2012).
`RESPONSE: Denied. Plaintiff’s Notice of Initiation of Treatment (“NOIT”) should be
`received within 21 days of the first date of treatment, pursuant to Fla. Stat. s. 627.736(5)(c).
`Plaintiff’s first date of service in this case was 01/23/2023. Given that the first date of
`service was 01/23/2023, Plaintiff’s NOIT should have been received by 02/12/2023;
`however, Plaintiff’s NOIT was actually received by Defendant on 03/11/2023. As such,
`Plaintiff’s NOIT was late pursuant to Fla. Stat. s. 627.736(5)(c). Additionally, pursuant to
`Fla. Stat. 627.736(5)(c) Medical bills for date of service 01/23/2024 should have been
`received on 02/27/2023, but they were actually received by Defendant on 03/11/2023. As
`such, those bills were late pursuant to Fla. Stat. 627.736(5)(c).
`5.
`Admit that the Defendant paid at least one (1) code at less than 80% of 200% of the
`Participating Physician's Fee Schedule Part B.
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`6.
`Defendant has denied payment to Plaintiff for treatment, medical services, supplies, or
`diagnostic testing provided to Chavela Gordon.
`RESPONSE: Denied.
`7.
`Admit that at least one (1) code paid at less than 80% of 200% of the Participating
`Physician's Fee Schedule Part B was paid at 80% of the amount billed.
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 2 of 8
`
`

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`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`8.
`Chavela Gordon's personal injury protection benefits from the subject accident have not
`been exhausted.
`RESPONSE: Admitted.
`9.
`Chavela Gordon's personal injury protection benefits from the subject accident were not
`exhausted prior to the date Plaintiff filed the instant complaint.
`RESPONSE: Admitted.
`10.
`Defendant has not denied personal injury protection coverage to Chavela Gordon
`regarding the accident referenced in the complaint.
`RESPONSE: Admitted.
`11.
`Admit that the Defendant paid at least one (1) code at 80% of the billed amount.
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`12.
`Admit the Defendant did not pay 100% of the billed amount of at least one (1) code that
`was billed below Participating Physician's Fee Schedule Part B.
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 3 of 8
`
`

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`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`13.
`The Explanations of Review produced in response to the subject medical provider's
`charges are true and correct representations of the charges received by Defendant, the amounts
`reimbursed by Defendant and the reasoning behind the reimbursement.
`RESPONSE: Denied as phrased. The Explanations of Review represent an initial
`evaluation of medical bills received. However, Defendant may correct, amend, update, or
`otherwise modify payment prior to initiation of this suit to ensure compliance with Florida
`Statute 627.736 and the subject insurance policy.
`14.
`Chavela Gordon has not failed to comply with any conditions precedent prior to filing
`this lawsuit.
`RESPONSE: Admitted.
`15.
`Admit Defendant elected to use the Participating Medical Fee Schedule Part B for its
`method of reimbursement, in its policy of insurance issued in this case.
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 4 of 8
`
`

`

`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`16.
`Plaintiff has not failed to comply with any conditions precedent prior to filing this
`lawsuit.
`RESPONSE: Admitted.
`17.
`Defendant limited reimbursement pursuant to the schedule of maximum charges under
`Section 627.736(5)(a)(1), Florida Statutes (2012).
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`18.
`Defendant did not make an assessment of evidence of usual and customary charges and
`payments accepted by the provider involved in the dispute, reimbursement levels in the
`community and various federal and state medical fee schedules applicable to motor vehicle and
`other insurance coverages, and other information relevant to the reasonableness of the
`reimbursement for the service, treatment, or supply beyond the schedule of maximum charges
`under Section 627.736(5)(a)(1), Florida Statutes (2012), to determine the reasonableness of the
`medical provider's charges.
`RESPONSE: Denied as phrased.
`19.
`Defendant used one or more Medicare coding policies or payment methodologies of the
`federal Centers for Medicare and Medicaid Services to limit reimbursement below the schedule
`of maximum charges under Section 627.736(5)(a)(1), Florida Statutes (2012).
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 5 of 8
`
`

`

`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`20.
`Admit Defendant determined the allowed amount for any code billed less than 200% of
`the Participating Medicare Fee Schedule, by comparing it to 200% of the Participating Medicare
`Fee Schedule.
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 6 of 8
`
`

`

`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`21.
`Admit Defendant applied a 20% reduction to at least one code that was billed less than
`200% of the Participating Medicare Fee Schedule.
`RESPONSE: Denied as phrased. All due and owing benefits and interest were paid pre-
`suit in accordance with the provisions of both the Florida no-fault statute and the subject
`automobile policy contract in the Personal Injury Protection endorsement, under Limit of
`Liability, Section F, subsection
`(f), which specifically allows
`for
`limitation of
`reimbursement to 200% of the allowable amount under Medicare Part B, after application
`of the deductible. Thus, per the subject insurance policy and No-Fault Statute, the most
`that could be due to a treating physician is 80% of the billed amount. In this case,
`Defendant asserts recoupment for overpayment/credit it made in error to Plaintiff for a bill
`submitted to Defendant by Plaintiff, because that service was payable at a lower rate, such
`that the recouped amount shall offset any amount claimed as due and owing by Plaintiff.
`CPT Code G0283 was allowed at $26.14.
`CPT Code 97140 was allowed at $58.32.
`CPT Code 97110 (2 units) was allowed at $126.00.
`CPT Code 98940 was allowed at $57.52.
`CPT Code 97012 was allowed at $32.76.
`CPT Code 97010 was allowed at $10.00.
`CPT Code 99203 was allowed at $237.94.
`CPT Code 99212 was allowed at $117.12.
`CPT Code S8949 was allowed at $100.00.
`Please see allowable amounts in the EOBs for Defendant’s initial evaluation of medical bills
`received. Please see Defendant’s Response to Plaintiff’s Demand and PIP Ledger for
`corrected, amended, updated, or otherwise modified payment prior to initiation of this suit.
`22.
`Admit Defendant breached the policy of insurance by paying an amount less than the
`Florida No Fault Statute,§ 627.736 (5)(a)(5), allows.
`RESPONSE: Denied. Furthermore, Defendant asserts recoupment for overpayment/credit
`it made in error to Plaintiff for a bill submitted to Defendant by Plaintiff, because that
`service was payable at a lower rate, such that the recouped amount shall offset any amount
`claimed as due and owing by Plaintiff.
`23.
`Admit Defendant does not have a signed copy of any "Deductible Election Form".
`RESPONSE: Denied.
`
`CERTIFICATE OF SERVICE
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 7 of 8
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`

`

`I certify that the foregoing document has been furnished to Jessica Pickeral, Esquire, Morgan &
`Morgan,
`P.A.,
`Primary E-mail:
`jpickeral@forthepeople.com,
`Secondary E-Mail:
`vcolon@forthepeople.com by e-mail on this 1st day of March, 2024.
`
`Law Office of Ignacio M. Sarmiento
`PO Box 7217
`London, KY 40742
`Telephone: (786) 843-4392
`Attorney for Defendant, Safeco Insurance Company Of Illinois
`
`/s/ Daniella L. Capote
`Daniella L. Capote, Esq., FBN 1031905
`Primary E-mail (eservice only): FLPIPMail@libertymutual.com
`Secondary E-mail: Daniella.Capote@libertymutual.com
`
`Case No.: 2024-SC-1434-O
`Basis Medical, LLC a/a/o Chavela Graham v. Safeco
`Page 8 of 8
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`