14 Fla. L. Weekly Supp. 647a
Insurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Insurer is not liable for balance of reduced claim despite fact that benefits were exhausted in payment of later-filed claims after medical provider filed suit and despite fact that provider resubmitted its claim with presuit demand letter prior to the benefits exhausting
CONCEPT EFL IMAGING CENTER, LLC., d/b/a CONCEPT OPEN IMAGING CENTER as Assignee for MaryBeth Atkinson, Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 2006SC012042XXXXMB, Div. RL. April 27, 2007. Janis Brustares Keyser, Judge. Counsel: Dena Sisk Foman, Vernis & Bowling of Palm Beach, P.A., North Palm Beach. Glenn E. Siegel, Palm Beach.
FINAL JUDGMENT FOR DEFENDANT
THIS CAUSE came before the Court for review on Defendant’s Motion for Summary Judgment. The Court, having heard argument, reviewed the pleadings, case law and being otherwise fully advised in the premises, hereby finds as follows:
1. Plaintiff, Concept EFL Imaging Center, LLC. d/b/a Concept Open Imaging Center as Assignee for MaryBeth Atkinson, filed this lawsuit on September 8, 2006 for personal injury protection (PIP) benefits for diagnostic services rendered to Ms. Atkinson for injuries she sustained in a motor vehicle accident. The Defendant was first served in this action with an Amended Complaint on October 4, 2006.
2. The pre-suit demand letter for this claim was sent by the Plaintiff on August 16, 2006. The Defendant responded to the pre-suit demand letter on September 5, 2006 advising the Plaintiff that it had paid pursuant to statutory requirements and believed that it had already paid a fair and reasonable amount for the claim submitted. The Defendant subsequently exhausted its contractual benefits on behalf of Ms. Atkinson through payment to another health care provider on September 27, 2006.
3. Defendant has moved for summary judgment based on the exhaustion of benefits claiming that Defendant has fulfilled its contractual obligations to the insured and cannot be required to pay above the contracted maximum amount of benefits. The Plaintiff has not claimed bad faith against the Defendant, however, the Plaintiff submits that since benefits were available when the Complaint was filed in this action, the Defendant’s Motion for Summary Judgment must fail.
4. Defendant relies primarily on the Fourth District Court of Appeal’s decision in Simon v. Progressive Express Insurance Company, 904 So. 2d 449 (Fla. 4th DCA 2005). The Plaintiff attempts to distinguish Simon on the grounds that in contrast to Simon, the Plaintiff in this case resubmitted its claim with its pre-suit demand letter prior to the benefits exhausting. This Court finds, however, that the following language in Simon entitles the Defendant to entry of a final summary judgment despite the fact that Progressive had notice prior to exhaustion of the benefits:
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. ld.
The foregoing language indicates that the Court in Simon contemplated that an insurance company would receive claims from providers after a lawsuit was filed and approved the company’s payment of these later claims to other health care providers. It is therefore
ORDERED AND ADJUDGED that the Defendant’s Motion for Summary Judgment is hereby granted. Judgment is entered in favor of the Defendant and the Plaintiff shall take nothing by this action and the Defendant shall go hence without day. The Court reserves jurisdiction to determine attorneys fees and taxable costs.
