Solomon v. Well Care HMO, Inc.

822 So. 2d 543, 2002 Fla. App. LEXIS 10332, 2002 WL 1625568
CourtDistrict Court of Appeal of Florida
DecidedJuly 24, 2002
DocketNo. 4D01-3150
StatusPublished
Cited by2 cases

This text of 822 So. 2d 543 (Solomon v. Well Care HMO, Inc.) is published on Counsel Stack Legal Research, covering District Court of Appeal of Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Solomon v. Well Care HMO, Inc., 822 So. 2d 543, 2002 Fla. App. LEXIS 10332, 2002 WL 1625568 (Fla. Ct. App. 2002).

Opinion

HAZOURI, J.

On September 18, 2000, Gladys Solomon and her husband, Alvin Solomon, (collectively, “the Solomons”) filed suit against Well Care HMO, Inc. (‘Well Care”), a health maintenance organization (“HMO”), for withholding or denying authorization of Gladys Solomon’s claim for coverage under a health benefit contract. The trial court granted Well Care’s Motion to Dismiss the Third Amended Complaint and dismissed the complaint with prejudice. We reverse.

The Third Anended Complaint generally alleges: Gladys Solomon obtained an Individual Health Benefit Contract from Well Care (“the Well Care contract”). Thereafter, her treating physician discovered uterine fibroids and recommended a total abdominal hysterectomy. “On June 11, 2000, Well Care provided authorization for the surgei-y for medical necessity only under authorization # 100049321 but did not guarantee payment of the claim, pending Well Care’s investigation of a potential pre-existing condition.” Well Care performed its investigation, determined that the pre-existing condition exclusion did not apply and guaranteed payment. Gladys Solomon underwent preoperative preparation for the surgery. On June 19, 1998, the day before the scheduled surgery, Well Care informed Gladys Solomon that it would not guarantee payment for the surgery. As a result, she did not undergo surgery. The Well Care contract provides a coverage exclusion for pre-existing conditions.

The complaint asserts causes of action for breach of contract (count I), fraud in the inducement (count II), fraud (count III), intentional infliction of emotional dis: tress (count IV), breach of implied covenant of good faith and fair dealing (count V), and loss of consortium (count VI). The breach of contract cause of action alleges, Well Care materially breached its promises and obligations under the plan by failing to authorize payment of benefits for a medically necessary surgery.”

Well Care moved to dismiss the Third Amended Complaint, arguing the six causes of action are claims for medical malpractice as defined in section 766.106(l)(a), Florida Statutes (2000), as they are predicated on and arise out of the alleged denial of medically necessary care and treatment, and the Solomons failed to serve presuit notice as required under sec[545]*545tion 766.106(2). Well Care further argued the dismissal should be with prejudice as the two-year statute of limitations for the claims expired on June 19, 2000, and they had not been served with presuit notice.

The Solomons argued that the ease involved Well Care’s failure to authorize payment of a claim and had nothing to do with whether the procedure was medically necessary. The Solomons asserted that Well Care did not deny coverage because the surgery was not medically necessary but rather because Well Care concluded that it was treatment for a pre-existing condition.

The trial court found that the complaint was based on Well Care’s alleged withdrawal of its authorization for a medically necessary operation, requiring the Solo-mons to serve Well Care with presuit notice under chapter 766, Florida Statutes (2000). The trial court further found that because the two-year statute of limitations on medical malpractice claims expired, the Solomons could not cure the deficiency.

A complaint asserting claims for medical malpractice that is filed before presuit notice requirements are met is subject to dismissal with' leave to amend, so long as the two-year statute of limitation period has not yet run; however, the cure is not available if the statutory period for initiating suit has run before the plaintiff attempts to fulfill presuit notice: requirements. See S. Neurosurgical Assocs., P.A. v. Fine, 591 So.2d 252, 255 (Fla. 4th DCA 1991). The parties do not dispute that if the claims are for medical malpractice, then the statutory period has run and the dismissal would be appropriate.

The Solomons contend the claims in the Third Amended Complaint are not for medical malpractice or medical negligence, as they do not challenge the professional judgment or skill of Well Care in providing medical care and treatment. They argue the trial court erred when it determined that the claims are subject to compliance with the presuit notice requirement set forth in chapter 766, and dismissed the complaint on that basis.

Section 766.106 requires plaintiffs to notify health care providers of their intent to initiate medical malpractice litigation. See, e.g., J.B. v. Sacred Heart Hosp. of Pensacola, 635 So.2d 945, 948-49 (Fla.1994); Patry v. Capps, 633 So.2d 9 (Fla.1994); Weinstock v. Groth, 629 So.2d 835 (Fla.1993); Paulk v. Nat’l Med. Enters. Inc., 679 So.2d 1289 (Fla. 4th DCA 1996). Section 766.106(2), provides:

After completion of presuit investigation pursuant to s. 766.203 and prior to filing a claim for medical malpractice, a claimant shall notify each prospective defendant by certified mail, return receipt requested, of intent to initiate litigation for medical malpractice.

A “claim for medical malpractice” is defined as “a claim arising out of the rendering of, or the failure to render, medical care or services.” § 766.106(l)(a), Fla. Stat. (2000). Presuit investigation under section 766.203, applies to “medical negligence” claims. See § 766.203(1), Fla. Stat. (2000) (“Presuit investigation of medical negligence claims and defenses ... shall apply to all medical negligence ... claims and defenses.”). “Medical negligence” is defined as “medical malpractice, whether grounded in tort or in contract.” See § 766.202(6), Fla. Stat. (2000).

A complaint does not state a medical malpractice claim for chapter 766 purposes, where the complaint does not allege that the defendant was negligent in the rendering, or the failure to render, medical care or services. See J.B. v. Sacred Heart Hosp. of Pensacola, 635 So.2d 945, 948-49 (Fla.1994). See also Silva v. Southwest [546]*546Fla. Blood Bank, Inc., 601 So.2d 1184, 1187 (Fla.1992) (“In ordinary, common parlance, the average person would understand ‘diagnosis, treatment, or care’ to mean ascertaining a patient’s medical condition through examination and testing, prescribing and administering a course of action to effect a cure, and meeting the patient’s daily needs during the illness.”).

The Solomons rely upon this court’s decision in Lane v. Health Options, Inc., 796 So.2d 1234 (Fla. 4th DCA 2001), when arguing their claims are not for medical malpractice. In Lane, the appellant filed suit against an HMO claiming negligence, breach of contract, bad faith, common law bad faith and deceptive and unfair trade practices for damages resulting from the HMO’s decision to decline authorization for a medical procedure. The complaint alleged:

Defendant [HMO] was negligent in that defendant made a negligent medical decision in contradiction to the treating doctor whom [sic] advised that a muscle flap was needed to cover the wound to prevent a bone infection. The Defendant in opposition to said medical advise [sic] made a medical decision to have a skin graft performed instead of the muscle flap. The skin'graft did not take and the skin receded from the bone leaving an open bone. The bone became infected and Plaintiff required numerous subsequent operations to correct the problem.

Id. at 1235.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Acosta v. Healthspring of Florida, Inc.
118 So. 3d 246 (District Court of Appeal of Florida, 2013)

Cite This Page — Counsel Stack

Bluebook (online)
822 So. 2d 543, 2002 Fla. App. LEXIS 10332, 2002 WL 1625568, Counsel Stack Legal Research, https://law.counselstack.com/opinion/solomon-v-well-care-hmo-inc-fladistctapp-2002.