Filing # 194988648 E-Filed 03/28/2024 08:53:08 AM
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`IN THE SMALL CLAIMS COURT OF THE NINTH
`JUDICIAL CIRCUIT IN AND FOR ORANGE
`COUNTY, FLORIDA
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`CASE NO.:
`DIV. NO.:
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`15455229
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`CENTRAL FLORIDA MEDICAL &
`CHIROPRACTIC CENTER, INC. D/B/A
`STERLING MEDICAL GROUP A/A/O MORGAN
`CHISOLM,
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`vs.
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`PROGRESSIVE SELECT INSURANCE
`COMPANY,
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`Defendant.
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`________________________________/
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`Plaintiff,
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`COMPLAINT
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`Central Florida Medical & Chiropractic Center, Inc. d/b/a Sterling Medical Group,
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`(hereinafter "Plaintiff"), as assignee of Morgan Chisolm, (hereinafter "Insured"), sues the
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`Defendant, Progressive Select Insurance Company, (hereinafter "Defendant"), pursuant to the
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`Ninth Judicial Circuit Court Administrative Order 2009-12-02 applies and alleges:
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`1.
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`This is an action for damages in the amount range of $500.01 to $2,500.00
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`dollars exclusive of interest, costs, and attorney’s fees.
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`2.
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`At all times material hereto, Defendant was a corporation duly licensed to
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`transact insurance in the State of Florida and maintained agents for transaction of its customary
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`business in Orange County, Florida.
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`3.
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`On or about May 3, 2023, the Insured was involved in a motor vehicle accident.
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`The Insured sustained personal injuries in, or as a result of, said accident.
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`4.
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`As a direct and proximate result of the personal injuries the Insured sustained in
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`the accident, the Insured incurred reasonable expenses for related and necessary medical and
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`rehabilitative treatment and therapy, supplies, diagnostic testing, nursing and remedial care
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`performed or provided by the Plaintiff in the State of Florida.
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`5.
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`Defendant issued an insurance policy that provided personal injury protection
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`(PIP) benefits required by law to comply with Section 627.730 - 627.7405, Florida Statutes,
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`and/or medical payment coverage. A copy of the policy is not available, but it is in the
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`possession of the Defendant. Plaintiff is not in possession of the policy and Defendant is not
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`prejudiced by the policy not being attached to this complaint.
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`6.
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`The above described policy was in full force and effect on the date of the
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`accident and provided PIP and/or medical payment coverage for the Insured for bodily injuries
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`sustained in said accident.
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`7.
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`Pursuant to all or a combination of the following, Plaintiff has standing to pursue
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`this action directly against the Defendant, and to collect all reasonable attorney's fees pursuant
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`to Sections 627.733 et seq., 627.736(4)(c), 627.736(8), and 627.428, Florida Statutes:
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`A.
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`B.
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`C.
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`8.
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`a written assignment of benefits wherein the Insured assigned to Plaintiff the
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`rights to any potential benefits under the PIP policy of insurance issued by the
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`Defendant (A copy of said assignment of benefits is contained in Exhibit "A");
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`an equitable or implied assignment (hereinafter "equitable assignment"), that
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`exists between the patient and Plaintiff wherein the patient assigned the rights to
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`any potential benefits under the PIP policy of insurance issued by the Defendant;
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`and/or
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`as the real party in interest as Plaintiff has a sufficient stake in the controversy
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`addressed in this count, will be affected by the outcome of this matter and is the
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`actual party that stands to lose or gain.
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`Defendant received notice of the covered losses.
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`9.
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`Defendant failed to make proper payment of said PIP benefits within thirty (30)
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`days as required by Section 627.736(4)(b), Florida Statutes.
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`10.
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`A demand for PIP and/or medical payment benefits was made for all reasonable
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`charges that were for necessary medical and rehabilitative treatment and therapy, supplies,
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`diagnostic testing, nursing, and remedial care related to the subject accident. (The medical
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`bills, charges, and items that are the subject of this claim are attached hereto as Exhibit “A”).
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`11.
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`The Plaintiff has performed all conditions precedent to entitle Plaintiff to recover
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`PIP and medical payment benefits for reasonable, related and necessary medical and
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`rehabilitative treatment and therapy, supplies, diagnostic testing, nursing and remedial
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`treatment regarding the above-described policy, or those conditions have been waived.
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`12.
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`Despite the fact that Defendant had no reasonable proof to establish that it was
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`not responsible for the payment, Defendant has failed to pay Plaintiff for covered losses.
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`13.
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`Due to Defendant’s failure to pay PIP benefits in accordance with Florida law,
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`Plaintiff has been required to retain the undersigned law firm for the prosecution of this lawsuit.
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`The Plaintiff has agreed to pay, and the attorneys have agreed to accept, any Court-awarded
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`attorneys’ fee.
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`14.
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`Defendant has failed to pay the applicable statutory interest, postage, penalties,
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`and the statutory attorney fees required by law.
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`15.
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`The determination of the reasonableness of charges is subject to Section,
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`627.736(5), Florida Statutes and Defendant’s policy language. To the extent Defendant has
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`made a legally sufficient election allowing it limit payment pursuant to the schedule of
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`maximum charges legally permitted by Section 627.736(5)(a)(1), Florida Statutes (2012)(or
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`Section 627.736(5)(a)(2), Florida Statutes (2008)), Plaintiff’s claim or claims do not exceed
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`those legally permitted limits.
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`16.
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`Plaintiff would derive a direct benefit from the Court ordering the Defendant to
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`pay benefits, interest, postage, penalty and attorney fees, even if Defendant pays all or some of
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`the disputed benefits before judgment is entered.
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`17.
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`Plaintiff is entitled to an award of reasonable attorneys' fees pursuant to Sections
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`57.041, 57.104, 627.428 and 627.736(8), Florida Statutes.
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`18.
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`Plaintiff is entitled to simple interest on the amount of said medical bills or
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`charges pursuant to Section 627.736(4)(c), Florida Statutes.
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`WHEREFORE, Plaintiff, Central Florida Medical & Chiropractic Center, Inc. d/b/a Sterling
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`Medical Group, as assignee of Morgan Chisolm, demands judgment against Defendant,
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`Progressive Select Insurance Company, for damages in the amount range of $500.01 to
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`$2,500.00 dollars exclusive of interest, costs, and attorney’s fees.
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`PLAINTIFF HEREBY DEMANDS A JURY TRIAL ON ALL ISSUES SO TRIABLE.
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`Respectfully submitted this 28th day of March, 2024.
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`/s/ Jessica Pickeral
`Jessica Pickeral, ESQUIRE
`Florida Bar No. 1003101
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`MORGAN & MORGAN, P.A.
`20 N. Orange Avenue, 4th Floor
`Orlando, FL 32801
`(407) 428-6243 – Phone
`4072042102 – Fax
`Primary Email: jpickeral@forthepeople.com
`Secondary Email: vcolon@forthepeople.com
`ncascio@forthepeople.com
`Attorneys for Plaintiff
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`###EFMESES###
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`Exhibit A
`Exhibit A
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`January 12, 2024
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`SENT VIA CERTIFIED MAIL
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`15455229
`David E. Krinsky
`Progressive Select Insurance Company
`600 N. Westshore Blvd Suite 200
`Tampa, FL 33609
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`Written Notice of Intent to Initiate Litigation
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`This is a demand letter under §627.736(10) as required by Florida Statute (effective date - January
`1, 2008) and/or §627.736(11)(prior statute), or under any policy of insurance
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`RE: 15455229 Sterling Medical a/a/o MORGAN CHISOLM vs PROGRESSIVE
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`Insured:
`Patient:
`Claim/Policy#:
`Date of Loss:
`Our File#:
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`Jason Chisolm
`Morgan Chisolm
`23-2387584
`05/03/2023
`15455229
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`Dear Sir/Madam:
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`This is a demand letter under section 627.736 (10), Florida Statutes, and under any policy of insurance.
`The personal injury protection (PIP) benefits (and medpay benefits if applicable), claimed are for payment
`of reasonable charges for related and necessary treatment, services, accommodations or supplies to the
`above-referenced patient. The below-identified provider has not been properly paid.
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`Name of medical provider rendering treatment, services, accommodations or supplies that form the basis
`of this claim: Central Florida Medical & Chiropractic Center, Inc. d/b/a Sterling Medical Group.
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`Specifically, this demand is for payment of the below listed amounts for the listed dates of service at the
`reasonable amount billed minus any payments received by Central Florida Medical & Chiropractic
`Center, Inc. d/b/a Sterling Medical Group from said PIP insurer. (Please note that if this policy contains
`medpay coverage, the amount demanded is at 100% of the reasonable billed amount minus any
`payments received from said PIP insurer). If the insurer has information supporting that a lesser amount
`is owed and/or this demand is not payable due to deductible, co-payment, exhaustion, Florida Statute
`§627.736(1)(a), §627.736(2), §627.736(4), §627.736(5), §627.736(6), §627.736(7), or for any other
`reason, please provide the appropriate explanation pursuant to §627.736(4)(b).
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`20 N. Orange Avenue, Suite 1600, Orlando, FL 32801 | (407) 420-1414 | ForThePeople.com
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`If the insurer has made an unambiguous election in its insurance policy pursuant to Fla. Stat. Section
`627.736(5)(a)(1)(2012), permitting the insurer to limit payment to 80% of 200% of the allowable amount
`under the Medicare Part B Physicians Fee Schedule and/or the 80% of the maximum reimbursable
`allowance under workers’ compensation, then the amounts demanded herein are subject to those legally
`permitted amounts. The policy of insurance is in the insurer’s possession, and the insured and/or its
`assignee is unable to determine the specific amount owed without this documentation.
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`If the insurer contends that it has made an election to limit payment subject to the schedule of maximum
`charges noted above, please recite to us or provide us with the portion of the insurance policy that
`provides for limiting payment to the schedule of maximum charges.
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`Please provide a copy of the PIP payout log and/or copies of all explanation of benefits/reimbursements
`that have been made on behalf of the above-referenced patient/claimant.
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`We dispute the payments made by the insurer and request the insurer to notify us that the policy limits
`under this section have been reached within 15 days after the limits have been reached as required by
`§627.736(6)(f).
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`The following is demanded:
`1. Billed amount of $2,475.16 or @ 80% $1,581.53, subject to applicable policy limits, and
`any proper election under §627.736(5)(a)(5) to limit payment to the schedule of maximum
`charges legally permitted under §627.736(5)(a)(1)-(4), pending verification of medical
`benefits for date(s) of service 05/05/2023 - 05/18/2023 made payable to Central Florida
`Medical & Chiropractic Center, Inc. d/b/a Sterling Medical Group and mailed to our office.
`Interest on the amount due, at the statutory rate, commencing 30 days after the date the
`bill for services (CMS 1500) was received by the carrier and up to the date payment
`made make payable to Morgan & Morgan P.A.
`3. Penalty of 10% of amount due (Maximum penalty $250.00) and certified or registered
`mail, return receipt requested, cost made payable to Morgan & Morgan P.A. our tax
`identification number is 59-2920684.
`4. The demand response must reference file number 15455229
`5. Electronic responses can be sent to pipcaseorlando@forthepeople.com or faxed to
`(407) 204-2164.
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`2.
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`Also, enclosed please find the following:
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`1. Assignment of Benefits
`2.
`Itemized Statement
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`Further, in the event the carrier decides to not honor this claim and/or demand, we hereby request or
`demand the carrier reserve or escrow sufficient benefits to satisfy this outstanding claim prior to any
`exhaustion of benefits, pending resolution of any action reasonably filed after this letter. We seek to
`preserve and pursue all rights as provided by law and to minimize or avoid litigation if possible.
`Additionally, we request any reply further denying or not satisfying this claim/demand to outline the exact
`reasons why the carrier denies this claim/demand for denied or overdue benefits and other damages.
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`Failure to fully and completely comply with this demand letter within 30 days will result in suit being filed
`for all amounts legally due, including applicable costs and attorney’s fees.
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`Govern yourselves accordingly.
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`Sincerely,
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`Hans Kennon, Esquire
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`Enclosure(s)
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` 15455229 Chisolm, Morgan
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`DATE
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`TOTAL
`CPT
`BILLED
`CODE
`AMOUNT
`$232.78
`05/05/2023 99203
`$83.43
`05/05/2023 97535
`$69.74
`05/11/2023 98940
`$40.17
`05/11/2023 97010
`$42.23
`05/11/2023 G0283
`$50.47
`05/11/2023 97012
`$76.22
`05/11/2023 97110
`05/18/2023 72141 $2,054.85
`05/18/2023 72148 $2,035.28
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`TOTAL $4,685.17
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`Page 1 of 1
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`(.STERLING
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`MEDICAL GROUP
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`Assignmentof Benefits
`I hereby authorize and direct you, my insurance company 3
`Veal \ \\_ and/or my attorney to pay directly to
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`Sterling Medical Group. (‘Assignee’) such as may due and owing Assigneefor services rendered by reason of accident,illness and
`for any otherbills due Assignee, and to withhold such sums from any disability benefits, medical payments, No-Fault benefits, or any
`other insurance benefits obligated as reimbursement from any settlement, judgmentor verdict on my behalf as may be necessary to
`adequately protect said Assignee. In the eventI do not have insurance coverage, I understandI remain personally responsible for
`payment of services rendered.I further give an irrevocablelien to said assignee gains any andall insurance benefits named herein and
`any andall proceeds of any settlement, judgmentor verdict which maybepaid to meas a result of the injuriesorillness for whichI
`have been treated by the Assignee. Thisis to act as an assignment of myrights and benefits to the extent of the Assignee’s services,
`provided.In the event my insurance companyis obligated to make payment to me upon charges made bythe Assigneeforits services,
`refuses to make such payment, upon such cause ofaction, that I might have or that might exist in my favor against such company,
`authorize Assignee to prosecute said cause of action either in my nameor Assignee’s and further authorize Assignee to compromise,
`settle or otherwise resolve said claim of action as they seefit.
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`Direction of Payment
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`I hereby authorize any insurance companyorattorney to pay directly to Assignee the amountofthis and/orfuturebills for services
`rendered.I also agree to pay in a current manner any difference betweenthe total charges and the amountpaid by the insurance
`companydirectly to Assignee.
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`PIP Log & Declaration Sheet Request
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`I hereby authorize Assigneeto release requested information, whichis pertinent to my case, to my insurance companyorthe attorney
`involved in this case. Pursuant to 627.4137 Florida Statues (2001). I hereby request a copyofthe pip log and declaration sheet, which
`reflects the policy limits available at the time ofthis accident, to be provided to this Assignee. I hereby authorize this Assignee to
`request and receive a copy of mypip periodically as they deem necessary. If any term or provision of this Assignment, Lien and
`Authorization or the application thereof to any personor circumstanceshall to any extent be invalid or unenforceable, the remainder
`of this Assignment, Lien and Authorization,or the application of such term or provision to persons or circumstances other than those
`as to whichit is held invalid or unenforceable, shall not be affected thereby, and each term andprovision ofthis Assignment, Lien and
`Authorization shall be valid and enforcedto the fullest extent of the law.
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`Reservation of Benefits
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`Be further advised, I am hereby placing you on notice pursuantto Florida case law that should you (the insurance company/carrier)
`deny, reduceorfail to pay any part of, or an entire bill which was submitted on my behalf from this health care provide,I (the
`assignor) as well as the assignee (health care provider) are requesting, in advance, that you reserve, or “act aside,” the amount reduced
`or denied until the dispute is resolved. Should you submita checkto this health care provider whichis less than the correct contractual
`amount, and contains any languagereferring to payments as “ Full and Final Payment,”I have instructed this health care provider to
`return the check to you (the carrier) and consider the bill still due and owing(i.e. a late paymentas defined in F.S. 627.736).
`Additionally, should the remaining amountof my benefits approach an amountwhere there would be insufficient funds to pay the
`amount reduced,orfailed to pay, please notify me (the assignor) and this health care provider (the assignee).
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` Health Care Provider:
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`830 CommedBlvd.Suite E
`Orange City,
`FL 32763
`Phone:
`(386) 456-3325
`Fax: (386) 860-7788
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`A
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