PROGRESSIVE AMERICAN INSURANCE COMPANY
v.
GABLES INSURANCE RECOVERY, INC., A/A/O LEYANIS MOR
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Progressive Insurance appeals the trial court's denial of its motion for summary judgment on exhaustion of benefits in a PIP insurance dispute. The appellate court reverses, holding that when an insurer reduces charges using the Medicare Part B fee schedule and benefits are exhausted before litigation, the insurer cannot be held liable beyond policy limits absent a showing of bad faith.
An insurer is not required to set aside reserve funds for reduced or denied claims and may assert exhaustion of benefits as a defense absent bad faith. When PIP benefits are exhausted before the amount owed is established, the insurer has fulfilled its contractual obligation and cannot be held liable for any amount, including nominal damages.
[1] An insurer is not liable for benefits above the statutory limit absent a showing of bad faith.
[2] An insurer is not required to set aside funds in anticipation of litigation over an unpaid claim to avoid paying more than its coverage limits.
Previewing 2 of 5 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“an insurer is not required to "set aside" funds in anticipation of litigation over the unpaid claim in order to avoid the risk of paying more than its coverage limits”
Establishes that insurers have no duty to reserve funds for disputed claims, supporting the reversal of the trial court's judgment
Previewing 1 of 3 key quotes on this case — the court’s exact language, pinpointed for members.
Join FLexlaw to unlock all legal intelligenceLeyanis Morales Perez and Alian Morales were injured in a car accident and assigned their PIP benefits to All X-Ray Diagnostic Services, Inc. Progress…
The full statement of facts, procedural history, and disposition for this case are member content.
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MILLAN, J.
Appellant, Progressive Express Insurance Company (“Progressive”) appeals the l;I‘l3.I cou1t’s denial of its Motion for Final Summary Judgment on Exhaustion of Benefits. For the reasons explained below, we reverse and remand for the entry of a final judgment consistent wlth this opinion. [*2] Leyanis Morales Perez and Alian Morales were injured in a car accident on August 15, 2008. Both sought medical services from All X-Ray Diagnostic Services, Inc. (“All X-Ray”), and assigned their right to recover PIP benefits to the company. All X-Ray submitted its bills to Progressive, and Progressive reduced the claim by applying the Medicare Part B fee schedule. Subsequently, All X~Ray reassigned the benefits to Gables Insurance Recovery, Inc. (“Gables”), who filed suit against Progressive on or about January 29, 2013. At the time the suit was filed, the PIP benefits were exhausted. Prior to trial, the parties filed competing motions for summary judgment on the issue of exhaustion of benefits. Gables argued Progressive should be exposed beyond its policy limit because Progressive erroneously reduced the claim. On the other hand, Progressive argued absent bad faith, Gables was not entitled to recover an amount in excess of the policy limit. Progressive also argued there is no requirement that an insurance company set aside a reserve fund for claims that are reduced or denied. The trial court entered an order granting Gables’ Motion for Partial Summary Judgment and Denying Progressive’s Motion for Final Summary Judgment. The trial court ruled that when an insurer “wrongfully or improperly” reduces a charge by using the Medicare Part B fee schedule, the insurer camot later assert exhaustion of benefits as an affirmative defense to escape liability. The case later proceeded to jury trial and the trial court entered a final judgment in Gables’ favor. We review the trial court’s ruling on the motion for summary judgment de novo. See Interested Underwriters v. SeaFreight Line, Ltd., 971 So. 2d 892, 894 (Fla. 3d DCA 2007). Following the trial court’s ruling in this case, the Third District Court of Appeal entered its opinion in Geico Indem. C0. v. Gables Ins. Recovery, Inc. a/a/0 Rita M Lauzan, 159 So. 3d 151 (Fla. 3d DCA 2014), which is binding on this Court. In Lauzan, the insured was involved in a car accident then sought treatment from a medical provider. Id. at 152-53. The insured assigned her policy benefits to the medical provider who later re-assigned the benefits to the plaintiff. Id. at 153. Thereafter, the medical provider submitted its bills to the insurance company, and the insurance company reduced the claim based on the Medicare Part B fee schedule. Id. The plaintiff then sued the insurance company alleging breach of contract for failure to pay PIP benefits. Id. The insurance company argued its liability was limited to the fee schedule in Section 627.736(5)(a)2.f, and regardless of the fee schedule, the insu1'ed’s PIP [*3] -< benefits were exhausted. Id. Subsequently, the trial court entered a final judgment in favor of the plaintiff Id O11 review, the Third District Court of Appeal reasoned an insurer is not required to “set aside” funds in anticipation of litigation over the unpaid claim in order to avoid the risk of paying more than its coverage limits. Id. at 154. As a result, the court held absent a showing of bad faith, the insurer cannot be held liable for benefits above the statutory limit. Id. at 155. Further, other district courts of appeal have also addressed this issue. See Simon v. Progressive Express Ins. C0., 904 So. 2d 449, 450 (Fla. 4th DCA 2005) (declining to create a requirement that an insurance company set aside a reserve fund for claims that are reduced or denied); Progressive Am. Ins. C0. v. Stand-Up MRI of Orlando, 990 So. 2d 3, 4 (Fla. 5th DCA 2008) (holding a PIP insurer is not liable for benefits once benefits have been exhausted unless there has been a showing of bad faith); Northwoods Sports Med & Physical Rehab, Inc. v. State Farm Mut. Auto. Ins. C0., 137 So. 3d 1049, 1057 (Fla. 4th DCA 2014) (clarifying that exhaustion of benefits extinguishes the provider’s right to further payments, as long as the exhaustion is prior to the establishment ofthe amount to which the medical provider is entitled under PIP). In the instant case, the facts are identical to the facts in Lauzan. Gables received an assignment from the insureds’ medical provider, All X-Ray. Once All X-Ray submitted its bill to Progressive, they also reduced the amount ofthe claim based on the Medicare Part B schedule, like the insurance company in Lauzan. When the trial court heard the summary judgment motions, the trial court was aware the PIP benefits were exhausted. At that hearing, the trial court confirmed that Gables was not asserting bad faith. Consequently, Progressive’s liability ended at the policy limit because there were no allegations of bad faith. As a result, Progressive was entitled to final summary judgment based on the exhaustion ofbenefits. Despite Gables’ concession that this Court is bound by Lauzan, Gables argues for the first time on appeal that it is entitled to nominal damages. No district court has addressed whether the insured, or their assignees, can recover nominal damages when the underlying claim has been obviated by the exhaustion ofbenefits. Nevertheless, this Court is guided by Sheldon v. United Servs. Auto. Ass ’n, 55 So. 3d 593 (Fla. lst DCA 2010), where a medical provider sought to maintain a lawsuit to pursue interest, penalties and/or attorneys’ fees even though the underlying PIP benefits were exhausted. In Sheldon, the Fifth District Court of Appeal explained [*4] once an insurer has paid out the policy limit, the insurer has fulfilled its contractual obligation and may not be held liable for any disputed benefits. Id. at 595-96. Here, Gables’ nominal damages argument is analogous to the medical provider’s argument that was rejected by the court in Sheldon. Since the benefits are exhausted, in this case Progressive may not be held liable, not even for a nominal amount. Therefore, in light of the analysis in Sheldon, Gables cannot maintain this suit for the entry of a nominal damages award. I Because the summary judgment issue is dispositive, We decline to address the remaining issues raised by the parties. This case is REVERSED and REMANDED for entry of a final judgment consistent with this opinion. WALSH and DE LA O, JJ., concur. COPIES FURNISHED TO COUNSEL
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- Dr. Robert D. Simon, M.D., P.A. v. Progressive Express Ins. Co., 904 So. 2d 449 (Fla. 4th DCA 2005)
- 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)
- Progressive Am. Ins. Co. v. Stand-Up MRI OF Orlando, 990 So. 2d 3 (Fla. 5th DCA 2008)
- GEICO Indem. Co. v. Gables Ins. Recovery, Inc., 159 So. 3d 151 (Fla. 3d DCA 2014)
- Sheldon v. United Servs. Auto. Ass'n, 55 So. 3d 593 (Fla. 1st DCA 2010)