13 Fla. L. Weekly Supp. 502a
Insurance — Personal injury protection — Coverage — Exhaustion of policy limits — Insurer was not required to set aside reserve fund for denied or reduced claims, and provider who filed suit for denied claim shortly before policy limits were exhausted is not entitled to additional PIP benefits beyond policy limits — Summary judgment granted in favor of insurer
DR. ROBERT D. SIMON, MD, PA (James Taffuri), Plaintiff, v. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 03-CC-27334-RJ. December 7, 2005. Sandra Bosso-Pardo, Judge.
FINAL SUMMARY JUDGMENT
This cause coming on to be heard upon Defendant’s Motion for Final Summary Judgment and the Court, having considered the Motion and arguments of both parties, hereby makes the following finding of facts:
1. This case involves a claim brought by Dr. Robert Simon, M.D., P.A., (hereinafter referred to as the Plaintiff) as an assignee of the insured, James Taffuri, against Progressive Express Insurance Company (hereinafter referred to as the Defendant) for benefits under a personal injury protection (PIP) policy. The policy of insurance extended to the insured provided for a $10,000.00 limit in PIP benefits, subject to a $2,000.00 deductible.
2. Following a May 1, 2003 automobile accident, the insured began receiving medical treatment with various providers. The bills for these treatments were submitted to the Defendant to be paid under the insured’s PIP policy. The Defendant paid the bills as submitted.
3. The insured began treating with the Plaintiff on or about June 30, 2003, and continued treating with the Plaintiff until August 2003. Progressive processed the Plaintiff’s bills as received, paying such bills based on usual and customary charges and denying one based on improper CPT coding.
4. The Plaintiff filed suit against Defendant on or about October 28, 2003.
5. The insured’s benefits were exhausted on April 5, 2004. There are no additional PIP benefits remaining for the Plaintiff under the policy of insurance.
6. Recently the Fourth District Court of Appeals issued an opinion in the case of Dr. Robert Simon, M.D., P.A. (Hon) v. Progressive Express Insurance Company, 904 So.2d 449 (Fla. 4th DCA 2005), upholding the lower court’s granting of a Motion for Summary Judgment in favor of the Defendant based on exhaustion of benefits. In the Simon (Hon) case, the benefits were exhausted shortly after the complaint was filed. The court declined to create a requirement that an insurance company set aside a “reserve” fund for claims that are reduced or denied. The court further held that it is a prerogative of an insurance company to pay, reduce, or deny claims. The court reasoned that requiring insurance companies to set aside funds for disputed claims would be to the detriment of the insured and other providers who submitted proper claims.
Therefore, the Court hereby Orders and Adjudges as follows:
7. There is no factual dispute that PIP benefits are exhausted under the Plaintiff’s insurance policy. As a matter of law, the Plaintiff, as an assignee, stands in the shoes of the assignor. See Cadle Co., II, Inc. v. Stamm, 633 So.2d 45, 46 (Fla. 1st DCA 1994).
8. As the Plaintiff stands in the shoes of the insured, it is not entitled to additional PIP benefits beyond the policy limits.
9. The Simon (Hon) case is controlling over the case at hand and therefore Final Summary Judgment is GRANTED in favor of Defendant.
10. Based on the above, Plaintiff, Robert D. Simon, M.D., P.A., is not entitled to recover any monies from Defendant, Progressive Express Insurance Company. Defendant, Progressive Express Insurance Company, shall go hence without day.
11. This Court specifically reserves jurisdiction to determine the issue of attorney fees and costs due to Defendant. [13 Fla. L. Weekly Supp. 629b]
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