13 Fla. L. Weekly Supp. 181a
Insurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Even though medical provider notified insurer of intent to dispute reduction or denial of payment before benefits were exhausted, insurer was not required to set aside disputed funds — Insurer’s motion for summary judgment granted
ROBERT D. SIMON, MD, PA (Elisama Pereira), Plaintiff(s), vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant(s). County Court, 15th Judicial Circuit in and for Palm Beach County, Civil Division. Case No. 502003CC027272. September 26, 2005. Susan Lubitz, Judge. Counsel: Joseph G. Murasko, Vernis & Bowling of Palm Beach, P.A., North Palm Beach. Jeff Vastola, West Palm Beach.
FINAL JUDGMENT FOR DEFENDANT
THIS CASE came before the court on Defendant’s Motion For Summary Judgment. The court, having considered argument, case law and the court record, finds as follows:
FACTS
Elisama Pereira’s automobile insurance policy with Defendant, Progressive Express Insurance Company (“Progressive”), provided for personal injury protection benefits of $10,000.00. Plaintiff, Robert D. Simon, MD, PA (“Simon”) provided medical services to Pereira for injuries sustained in a motor vehicle accident. Simon submitted bills for reimbursement to Progressive for treatment to Pereira under her policy of insurance pursuant to an assignment of benefits. Progressive reduced or refused payment for some bills. Simon notified Progressive that he intended to dispute the reduction or denial of payment. Subsequent to receiving notice, Progressive paid other providers and exhausted Pereira’s PIP benefits under her policy.
DISCUSSION
In Simon vs. Progressive Express, 30 Fla. L. Weekly D1156b (Fla. 4th DCA, May 4, 2005) the court affirmed a lower court’s judgment in favor of Progressive because Progressive had paid $10,000.00 in benefits. Even though Simon had submitted his claim prior to Progressive’s payment to another medical provider, he failed to notify Progressive of his intent to dispute the reduction or denial of payment.
Simon argues that his notice to Progressive of his intent to dispute the reduction or denial of payment before Progressive exhausted Pereira’s benefits under the policy imposed a duty upon Progressive to set aside the disputed funds. However, the court’s reasoning in Simon vs. Progressive, Ibid. is applicable to the present case, even though Progressive had notice. The court stated:
“We decline to create a requirement that an insurance company set aside a ‘reserve’ fund for claims that are reduced or denied. Simon does not contend that the denial or reduction of its claim was in bad faith, or that Progressive had manipulated, or acted improperly, in reducing it.
If we were to accept Simon’s theory that a ‘reserve’ or ‘hold’ provision must be automatically applied to any available funds at the time a claim is submitted, it would result in unreasonable exposure of the insurance company and would be to the detriment of the insured and other providers with properly submitted claims. Under such a theory, all potential payments to a service provider that were denied, or were subject to a reduction, would have to be held in reserve until the statute of limitations period expired or a suit was filed and concluded. This would delay and reduce availability of funds for the payment of claims to other providers and would be inconsistent with the PIP statute’s ‘prompt pay’ provisions. See § § 627.613, and 627.662(7), Fla. Stat. (provision established to expedite payment to service providers). It is the obligation of insurance companies to attempt to settle as many claims as possible. Farinas v. Florida Farm Bureau General Insurance Co., 850 So.2d 555, 560 (Fla. 2003). It is also a prerogative of insurance companies to pay, reduce, or deny claims. Id.
Based on the foregoing, it is
ORDERED AND ADJUDGED as follows:
1. Defendant’s Motion For Summary Judgment is granted.
2. Plaintiff take nothing by this action and Defendant shall go hence without day.
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