Key Takeaway
Florida appeals court ruling on Progressive vs Back on Track regarding 80% PIP reimbursement rates and statutory schedule of maximum charges interpretation.
PROGRESSIVE AMERICAN INSURANCE CO. vs BACK ON TRACK, L L C, A/A/O OPHELIA BAILEY, No. 2D21-541 (Fla 2d DCA 2022)
(1) “The court entered an order denying Progressive’s motion and granting BOT’s motion; the
order states that the ruling was based on Geico Indemnity Co. v. Accident & Injury Clinic, Inc. ex rel. Irizarry, 290 So. 3d 980 (Fla. 5th DCA 2019), and reflects the court’s conclusion that Progressive
“was required to pay 80% of the applicable fee schedule amount for charges … or to pay the charge at 100% of the full amount billed for those charges billed below 80% of the schedule of
maximum charges.”
(2) “Summarizing, these cases establish that a PIP insurer whose policy includes a notice that it may use the statutory schedule of maximum charges to determine provider reimbursements must (1) pay 100 percent of the amount billed if a provider charges less than 80 percent of the amount allowed under the schedule of maximum charges and (2) pay 80 percent of the allowable amount under the applicable schedule of maximum charges for charges that exceed 80 percent of 100 percent of the allowable amount calculated under the applicable schedule of maximum charges. As we next explain,
we disagree with this proposition”
(3) “Given the full context of these provisions, a reasonable reading of the statutory text requires that reimbursement limitations based on the schedule of maximum charges be understood—as State Farm contends—simply as an optional method of capping reimbursements rather than an exclusive
method for determining reimbursement rates. By its very nature, a limitation based on a schedule of
maximum charges establishes a ceiling but not a floor.”
(4) “Progressive’s payment of BOT’s charges at 80 percent of the amount that BOT itself chose to bill unquestionably satisfied Progressive’s obligation under the coverage mandate—that is, to reimburse BOT for 80 percent of the reasonable expenses BOT incurred in treating Progressive’s insured, Ms. Bailey.”
Related Articles
- Understanding the CPLR 3212(g) paradigm for summary judgment motions
- Critical timing rules for CPLR 3212(a) summary judgment motions in New York
- When partial compliance isn’t enough for no-fault verification requirements
- Understanding the amendments to no-fault regulations and their implications
- New York No-Fault Insurance Law
Common Questions
Frequently Asked Questions
What is New York's no-fault insurance system?
New York's no-fault insurance system requires all drivers to carry Personal Injury Protection (PIP) coverage. This pays for medical expenses and lost wages regardless of who caused the accident, up to policy limits. However, you can only sue for additional damages if you meet the 'serious injury' threshold.
