Ms. Pressley was allegedly injured in an accident in 2004. Her medical treatment for the accident related claims was paid by her health insurer. When she recovered a settlement against the at-fault driver, the health insurer sought reimbursement of its lien. Thereafter, Ms. Pressley filed suit against her PIP insurer, demanding that they pay the lien. The bills were not submitted by the health care providers. The treatment was rendered well over 35 days before the bills were submitted and the bills were not submitted on properly completed CMS-1500s. Thus, the bills were not submitted in compliance with §627.736(5)(c)1 or 627.736(5)(d).

The Trial Court determined that these statutory provisions applied only to medical providers and that an insured was not required to comply when submitting medical bills. Finding no evidence to dispute that the insured's sworn testimony that the treatment was reasonable, necessary and related, the court granted summary judgment in favor of the insured.

The First DCA reversed, finding that the insurer owed no PIP benefits because neither the provider nor the insured had complied with the requirements of §627.736(5). Finding that §627.736(5)(c)1 was clear and unambiguous and should be accorded its plain meaning, the court held that it set forth the exclusive procedures for payment of PIP benefits from the no-fault insurer under a PIP policy. This provision therefore mandated that the statement of charges for treatment and services "must be furnished to the insurer by the provider and the PIP insurer is only obligated to pay those bills submitted by the provider within the statutory time period." Id. at 108. Specifically, the court noted that the PIP statute had no provision for submission of medical bills by an insured or other third party. (citing Warren v. State Farm Mut. Auto. Ins. Co., 899 So.2d 1090 (Fla. 2005) and Federated Nat'l Ins. Co. v. Physicians Charter Servs., 788 so.2d 403 (Fla. 3rd DCA 2001)).

Moreover, the court noted that allowing the insured to circumvent the payment procedures outlined in (5)(c)1 would render the statutory time limitations in the statute useless. The court specifically noted,

Ms Pressley's inability to recover the PIP benefits under her policy could have been avoided by her promptly notifying State Farm of the accident as required by the policy ... and by her notifying her medical providers that her injuries were the result of a motor vehicle accident so that the medical providers would have been able to file a timely claim for payment with State Farm.

Id.

In addition, the court rejected any argument that this ruling was inconsistent with the opinions from other DCA that allowed an entity other than a medical provider to recover PIP benefits. The court noted that those entities were entitled to recover only because they had a valid assignment of benefits from the insured. In this case, there was no assignment of benefits.

The court concluded that because the medical providers had not submitted statement to State Farm in compliance with the requirements of §627.736(5)(c)1, the benefits were not overdue and the insured did not have any cause of action against the insurer.

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