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Peer Review

Insurance carriers are able to withhold personal injury protection (“PIP”) payments to medical providers by using several different methods. One such method is the use of peer reviews. Peer reviews of the patients medical records are conducted by physicians that have been retained by the insurance company. The peer review physician is provided with the patients’ medical records, reviews them, and produces a report on them without ever meeting with the patient or the patients treating physicians. Peer review reports are virtually always in the insurance companies favor, allowing the insurance company to deny future payment of benefits

Peer Review Concluding Treatment is Not Reasonable, Related, or Necessary

Courts in Florida have interpreted the PIP statute in the favor of insurance companies in cases where denial of PIP benefits is based on peer review reports. The Fourth District Court of Appeal held that under the Statute, a medical report is still valid even when it does not indicate that the physician either physically examined the patent or based their opinion on an independent medical examination. United Auto. Ins. Co. v. Hollywood Injury Rehab Center, 27 So. 3d 743 (Fla. 4th DCA 2010). The holding in United Auto v. Hollywood Injury allows insurance companies to deny benefits based solely on a peer review report.  The Third District Court of Appeal in Florida held that a doctor’s peer review, that concluded the plaintiff’s medical treatment was not reasonable, related or necessary, constituted a “valid medical report” under Section 627.736(7)(a) even though it was not obtained before the insurer denied PIP benefits. United Auto. Ins. Co v. Prof’l Med. Group, Inc., (Fla. 3d DCA 2009)