Miami Appellate Court Rules no Adjudication of Fraud Necessary to Plead Fraud in PIP Lawsuit

The Miami-Dade County 11th Circuit (sitting in its appellate capacity) overturned a County Court decision of Judge Ana Maria Pando, now ruling that an insurer was not required to obtain an adjudication of fraud prior to pleading as an affirmative defense fraud, under 627.736(5)(b)(1)(c).

Florida Statute 627.736(5)(b)(1) provides that:

An insurer or insured is not required to pay a claim or charges:

a. Made by a broker or by a person making a claim on behalf of a broker;
b. For any service or treatment that was not lawful at the time rendered;
c. To any person who knowingly submits a false or misleading statement relating to the claim or charges; …
In the PIP suit at issue, the medical provider argued that under Florida Statute 817.234 there are certain criteria set forth for what is considered a false or fraudulent insurance claim and in order to plead fraud the elements of 817.234 must be met. The Miami appellate court disagreed and ruled that even without an adjudication of fraud an insurer is authorized and allowed to plead fraud as an affirmative defense.
United v. East Coast Medical (Alberto Abdullah), FLWSUPP 1907ABDU

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