DR. ROBERT D. SIMON, M.D., P.A., A/A/O ERIC HON, APPELLANT/APPELLEE,
v.
PROGRESSIVE EXPRESS INSURANCE COMPANY, APPELLEE/APPELLANT
AI-generated. These summaries, headnotes, and key points are machine-generated and may contain errors or omissions. Always verify against the full opinion text below. Not legal advice.
A physician who accepted a reduced insurance payment for medical services later sought to recover the balance of his claim, arguing the insurer should have held funds in reserve pending resubmission of additional documentation. The court affirmed summary judgment for the insurer, holding that acceptance of partial payment without notice of intent to resubmit extinguished any priority claim to undisbursed funds.
The insurer is not required to hold funds in reserve for claims that are reduced or denied when the provider accepts partial payment without notifying the insurer of intent to resubmit. A provider who accepts partial payment without such notice does not retain a priority claim to undisbursed funds, and the insurer may properly allocate those funds to other providers with properly submitted claims.
[1] An insurance company is not obligated to maintain a reserve fund for claims that are denied or reduced, especially when the provider accepts partial payment without prote…
[2] Accepting partial payment of a claim without protest waives any right to later demand the full amount or to claim priority over other disbursements.
Previewing 2 of 4 headnotes on this case. FLexlaw’s editorially structured points of law — every proposition, pinpointed — are reserved for members.
Join FLexlaw to unlock all legal intelligence“Although Simon had the initial option of re-submitting the claim and providing additional information under the PIP statute, he accepted payment and failed to re-submit the claim.”
Establishes that Simon had the procedural opportunity to resubmit but failed to exercise it or provide notice of his intention to do so.
Previewing 1 of 3 key quotes on this case — the court’s exact language, pinpointed for members.
Join FLexlaw to unlock all legal intelligenceDr. Robert Simon provided medical services to an auto accident victim covered by Progressive Express Insurance. Progressive reduced Simon's claim base…
The full statement of facts, procedural history, and disposition for this case are member content.
Join FLexlaw to unlock all legal intelligence© FLexlaw, Inc. — AI-generated enrichments are proprietary. All rights reserved.
Explore caselaw by topic → Browse Priority Of Claims cases and more on FLexlaw
STONE, J.
Physician, Robert Simon (Simon), accepted a reduced payment from Progressive Express Insurance (Progressive) for services rendered to a policy holder who had been in an auto accident. Simon cashed the payment check without protest. Before paying Simon, Progressive informed him, along with other providers whose claims are reduced or denied, that, as established by section 627.736, Florida Statutes (PIP statute), upon submission of new information, a denied or reduced claim would be reconsidered. At a later date, Simon resubmitted the claims for the balance. Progressive then advised Simon that the remaining funds were committed to another provider because he, Simon, accepted the partial payment without advising Progressive that the claim would be re-submitted. Simon claims Progressive was under the obligation to hold a sum in reserve indefinitely to cover the partially denied claims. Summary judgment was granted in favor of Progressive. We affirm.
Although Simon had the initial option of re-submitting the claim and providing additional information under the PIP statute, he accepted payment and failed to re-submit the claim. Simon claims Progressive should not have paid, or committed to pay other providers because Progressive knew he had a vested interest in the undisbursed funds. He asserts that, under the “English rule,” he was first in time and first in right because he filed his claim before actual disbursement of the committed funds. Thus, Progressive was liable for payment even if its obligation was depleted by setting aside or disbursing the committed funds to the other provider, whose treatment had commenced earlier than Simon’s.
We conclude that Simon did not have a priority claim against the funds remaining undisbursed. He accepted the partial payment, without notifying the insurance company that an amended claim was forthcoming. 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. 4th DCA 2003). It is also a prerogative of insurance companies to pay, reduce, or deny claims. Id.
We also find no reversible error as to the other issues raised. We affirm the judgment in favor of Progressive.
GUNTHER and STEVENSON, JJ., concur.
Cases With Similar Vibessemantic neighbors from the corpus
Citator
Cited By (11 total)
-
Northwoods Sports Med. & Physical Rehab., Inc. v. State Farm Mut. Auto. Ins. Co. & USAA Cas. Ins. Co., 137 So. 3d 1049 (Fla. 4th DCA 2014)…6(5)(a)(2)(f). This Court’s entry of final summary judgment is premised solely on [State Farm]’s exhaustion of benefits defense. At the behest of Northwoods, the county court certified three questions: 1. DID SIMON V. PROGRESSIVE EXPRESS INS. CO., 904 So. 2d 449, 450 (Fla. 4TH DCA 2005) ABROGATE THE ENGLISH RULE OF PRIORITIES AS ANNOUNCED BY THE FLORIDA SUPREME COURT IN BOULEVARD!]NATIONAL BANK OF MIAMI V. AIR METAL INDUSTRIES, INC., 176 So. 2d 94 (Fla.1965) AND APPLIED TO PIP CASES IN STATE FARM FIRE AND C…1 / 3
-
Progressive Am. Ins. Co. v. Stand-Up MRI OF Orlando, 990 So. 2d 3 (Fla. 5th DCA 2008)…of a showing of bad faith on the part of Defendant.” We agree. We also agree that there is no legal requirement that an insurer set aside a reserve fund for claims which are reduced or denied.2 As the court in Simon v. Progressive Express Ins. Co., 904 So. 2d 449, 450 (Fla. 4th DCA 2005), reasoned, requiring an insurer to maintain a reserve fund for disputed claims “would result in unreasonable exposure of the insurance company and would be to the detriment of the insured and other providers with properly su…
-
GEICO Indem. Co. v. Gables Ins. Recovery, Inc., 159 So. 3d 151 (Fla. 3d DCA 2014)…e Appellate Division filed its opinion in the instant case — two other District Courts of Appeal had addressed whether an insurer could be liable for PIP benefits above the $10,000 statutory limit. In both Simon v. Progressive Express Insurance Co., 904 So. 2d 449 (Fla. 4th DCA 2005), and Progressive American Insurance Co. v. Stand-Up MRI of Orlando, 990 So. 2d 3 (Fla. 5th DCA 2008), the Fourth and Fifth Districts respectively held that a showing of bad faith -or impropriety on the part of [*155] the insurer…
Previewing 3 of 11 citing cases — full citator treatment, depth of discussion, and citing context are member features.
Join FLexlaw to unlock all legal intelligenceAuthorities Cited
- Farinas v. Fla. Farm Bureau Gen. Ins. Co., 850 So. 2d 555 (Fla. 4th DCA 2003)