Lessons from Rivera v. State Farm Florida Third District Court of Appeal 2021
Florida’s PIP statute imposes strict mandatory requirements on presuit demand letters. A provider’s failure to comply with Section 627.736(10), Florida Statutes, is not a technical defect. It is a substantive failure that can result in summary judgment for the insurer, even where benefits may otherwise be owed.
In Rivera v. State Farm Mutual Automobile Insurance Company, decided February 24, 2021, the Third District Court of Appeal reaffirmed that strict specificity is required and that courts will not excuse vague, incomplete, inconsistent, or imprecise presuit demands.
This article explains exactly what must be included in a valid presuit demand and why precision matters.
When a Presuit Demand May Be Sent
A presuit demand may not be sent until the claim is overdue.
Under Section 627.736(10)(a), the presuit demand letter is a condition precedent to filing suit and may only be sent after the insurer’s statutory time to pay has expired, including any additional time permitted under Section 627.736(4).
Sending a demand prematurely renders it invalid.
The Demand Must Clearly Identify Itself as a Statutory Presuit Demand
The statute requires the notice to expressly state that it is a demand letter under Section 627.736.
The court in Rivera emphasized that the purpose of the presuit demand is not merely to notify the insurer of a dispute. The demand must inform the insurer of the exact amount that must be paid to avoid litigation.
General billing correspondence, payment inquiries, or informal requests do not satisfy the statute.
Required Identifying Information Must Be Included
A valid presuit demand must state with specificity the following information.
The full and correct name of the insured as it appears on the policy
The applicable claim number or policy number
If the claimant is a medical provider, a copy of the assignment of benefits
Failure to include this information may result in dismissal.
The Medical Provider Must Be Correctly Identified
To the extent applicable, the demand must identify the name of the medical provider that actually rendered the treatment, services, accommodations, or supplies forming the basis of the claim.
In Rivera, the demand identified an incorrect or nonexistent provider. The court held that insurers are not required to investigate, reconcile errors, or guess which provider is seeking payment. Accuracy is mandatory.
An Itemized Statement Is Mandatory and Precision Is Required
Section 627.736(10)(b)3 requires the presuit demand to include an itemized statement specifying each exact amount claimed to be due, the date of treatment, service, or accommodation, and the type of benefit claimed.
The Rivera court made clear that the following are insufficient.
- Estimated or averaged amounts
- Inconsistent dates or service counts
- Incomplete benefit calculations
Each disputed charge must be clearly broken down so the insurer can evaluate and cure the alleged underpayment.
The Demand Must Account for Payments Previously Made
A presuit demand must credit the insurer for all prior payments.
A demand that lists total charges without deducting payments already issued does not state the exact amount due. The insurer is entitled to know precisely what amount will resolve the dispute.
Insurers are not required to calculate the balance from their own records or guess at the cure amount.
The Purpose of the Presuit Demand
The legislative purpose of Section 627.736(10) is to encourage quick resolution of PIP disputes and reduce unnecessary litigation.
A compliant demand must clearly communicate the following.
- These are the exact dates of service
- These are the exact amounts still owed
- This is the exact total required to avoid suit
Anything less defeats the statutory purpose.
No Substantial Compliance Standard Applies
The Rivera court rejected arguments that a demand is sufficient simply because the insurer had enough information or could infer the missing details.
Section 627.736(10) requires strict compliance. Inaccurate, vague, misleading, or inconsistent information does not satisfy the statute.
Consequences of a Deficient Presuit Demand
If a presuit demand fails to comply with Section 627.736(10), the lawsuit is subject to summary judgment, attorney fees may be denied, and the provider must serve a new compliant demand before refiling suit.
As the Third District held in Rivera, the correct remedy is judgment in favor of the insurer.
Key Takeaways for Providers
- Send the presuit demand only after the claim is overdue
- Clearly state that the letter is a presuit demand under Section 627.736
- Accurately identify the insured, policy number, and provider
- Include a precise itemized statement listing each exact amount, date of service, and type of benefit claimed
- Account for all prior payments and demand only the remaining balance
- Avoid estimates, averages, inconsistencies, or assumptions
Note:
This article is for general informational purposes only and does not constitute legal advice. Providers should consult qualified legal counsel regarding compliance with Florida PIP presuit requirements.
