Advanced Spine Centers, Inc. v. Amica Mutual Insurance

2008 Mass. App. Div. 241, 2008 Mass. App. Div. LEXIS 35
CourtMassachusetts District Court, Appellate Division
DecidedOctober 22, 2008
StatusPublished

This text of 2008 Mass. App. Div. 241 (Advanced Spine Centers, Inc. v. Amica Mutual Insurance) is published on Counsel Stack Legal Research, covering Massachusetts District Court, Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Advanced Spine Centers, Inc. v. Amica Mutual Insurance, 2008 Mass. App. Div. 241, 2008 Mass. App. Div. LEXIS 35 (Mass. Ct. App. 2008).

Opinion

Greco, P.J.

As the Supreme Judicial Court recently reiterated, the Massachusetts no-fault insurance system “was intended to control the costs of compulsory automobile insurance.” Metropolitan Prop. & Cas. Ins. Co. v. Blue Cross & Blue Shield of Mass., Inc., 451 Mass. 389, 394 (2008). To help effectuate that goal, the Legislature in G.L.c. 90, §34A set out a ‘“coordination of benefits’ scheme providing for the sharing of costs between automobile and health insurers.” Id. at 391. On this appeal, we are called upon to determine the scope of that coordination.

There has never been a dispute about the facts in this case. The trial judge heard the matter on a “Case Stated,” and found for Arnica Mutual Insurance Company (“Arnica”). Although Advanced Spine Centers, Inc. (“Advanced”) filed requests for rulings of law, no action was taken on them. This appeal was taken under Rule 8C of the Dist/Mun. Cts. R. A D. A. In 402 Rindge Corp. v. Tsao, 2002 Mass. App. Div. 30, we noted that an appeal is available where the trial judge agreed to be bound by the agreed statement of facts, and where only a question of law remained for the court's determination. Id. at 32 n.5. Essentially, that is the posture of this appeal. “Thus we have before us everything which was before the trial judge, and we decide the questions of law involved unaffected by his decision.” Tucci v. DiGregorio, 358 Mass. 493, 494 (1970).

The Case Stated and the accompanying documents indicate the following. On August 16,2002, Carlos Pena (“Pena”) was injured in an accident while an occupant in a vehicle insured by Arnica. From August 21 through November 25,2002, he was treated by chiropractors employed by Advanced. Pena’s injuries were causally related to the accident; the treatment provided by Advanced was necessary; and a personal injury protection (“PIP”) application and Advanced’s bills were timely submitted to Arnica. Pena had a health insurance policy with Tufts Health Plan (‘Tufts”), and so notified both Advanced and Arnica. When Advanced sought payment from Arnica in the amount of $4,330.00, Arnica paid $2,000.00 and notified Advanced and Pena that the balance had to be submitted to Tufts for consideration. Advanced thereupon submitted all of the $4,330.00 in bills to Tufts. In response, Tufts paid only the bill for the initial examination ($175.00); it declined to pay $2,135.00 of the balance on the grounds that Advanced was not within Tufts’s network of providers, and the treatments and services administered were not covered by Pena’s contract with [242]*242Tufts. When notified of the action taken by Tufts, Arnica paid an additional $385.00, leaving an unpaid balance of $1,770.00, which Advanced sought in this lawsuit.

A closer examination of the bills submitted by Advanced and Arnica’s responses (Exhibits B and D to the Case Stated) reveals the following. From August 21, 2002 to November 19, 2002, Pena underwent continual, often daily, treatment with Advanced. For each day of treatment, Advanced billed for various items, some treatments repeated each time, others added here and there. The course of treatment, however, was, with some exceptions, generally consistent during the whole period. Although the Case Stated does not indicate when Advanced submitted its bills, Arnica made the $2,000.00 payment referred to above by letter dated November 12, 2002. Advanced applied the $2,000.00 to its charges chronologically, starting with the earliest date of service. Thus, the $2,000.00 payment covered all services rendered through September 25,2002. As noted above, Arnica initially declined to make any further payments, but did subsequently pay an additional $385.00. With respect to the bills for services provided after September 25,2002, it would appear from our own review of the exhibits that Tufts did not pay (1) $1,050.00 of those charges because Advanced was not a Tufts provider, and (2) $880.00 of them because they were not covered by Pena’s policy.

Arnica argues that it was entitled, indeed required, to look at all of the bills from the beginning of Pena’s treatment and pay only those for services that were not covered by Tufts, and that it could decline to pay for any services that Tufts would have paid for but for the fact that Pena chose to go to a chiropractor outside of Tufts’s network of providers. Advanced, on the other hand, argues that the PIP statute requires that the insurer pay the initial $2,000.00 of bills without factoring in the existence of health insurance in any way. Under this theory, Arnica would be able to consider the availability of Pena’s health insurance only after it had paid out $2,000.00 in benefits. To put the issue more starkly, if Arnica is right, a PIP insurer would never have to pay a cent if the motorist, or an occupant, had health insurance, but chose to go out of its network of providers for services that would have otherwise been covered.

We must start with the statute. Stripped of language irrelevant here, ‘“[p]ersonal injury protection’... provide[s] for payment to the named insured... [and to] a guest occupant... of all reasonable expenses incurred within two years from the date of accident for necessary medical, surgical, x-ray, and dental services ... to the amount or limit of at least eight thousand dollars. ...” G.L.c. 90, §34A. However, “ [n] otwithstanding the foregoing, personal injury protection provisions shall not provide for payment of more than two thousand dollars of expenses incurred within two years from the date of accident for... [such] services... if, and to the extent that, such expenses have been or will be compensated... pursuant to any policy of health, sickness or disability insurance....” Id. A claim for PIP benefits “shall be presented to the [insurance] company providing such benefits as soon as practicable after the accident occurs ..., and in every case, within at least two years from the date of the accident.. .. [PIP] benefits ... shall be due and payable as loss accrues, upon receipt of reasonable proof of the fact and amount of expenses and loss incurred....” G.L.c. 90, §34M.

We take this language to mean that the PIP insurer must pay up to $2,000.00 in benefits for injuries causally related to the accident regardless of whether the injured party has health insurance, provided the bills were reasonable and the treatment necessary. Arnica argues that under the statute, it is not required to pay more [243]*243than $2,000.00, but may pay less if the claimant has health insurance. However, the statute sets out an initial obligation to pay and then provides for an exception. By analogy, for the initial $2,000.00 of expenses, the PIP insurer is the primary plan that “must pay or provide its benefits as if the secondary plan or plans did not exist,” 211 CMR §38.05(1), while for expenses between $2,000.00 and $8,000.00, it becomes a secondary plan that “may take the benefits of another plan into account.” Id. §38.05 (2). See Metropolitan Prop. & Cas. Ins. Co., supra at 398. More directly, we see nothing in the case law supporting Arnica’s position.

As discussed in Pinnick v. Cleary, 360 Mass. 1 (1971), with the passage of “no-fault,” the Legislature set up an arrangement between a motorist and his automobile insurer. The insured gets “the security of prompt and certain recovery to a fixed amount of the most salient elements of his out-of-pocket expenses.... In return for this he surrenders the possibly minimal damages for pain and suffering....” (emphasis supplied). Id. at 6.

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Related

Tucci v. DiGregorio
265 N.E.2d 570 (Massachusetts Supreme Judicial Court, 1970)
Pinnick v. Cleary
271 N.E.2d 592 (Massachusetts Supreme Judicial Court, 1971)
Creswell v. Medical West Community Health Plan, Inc.
644 N.E.2d 970 (Massachusetts Supreme Judicial Court, 1995)
Dominguez v. Liberty Mutual Insurance
706 N.E.2d 647 (Massachusetts Supreme Judicial Court, 1999)
402 Rindge Corp. v. Ming Tsao
2002 Mass. App. Div. 30 (Mass. Dist. Ct., App. Div., 2002)

Cite This Page — Counsel Stack

Bluebook (online)
2008 Mass. App. Div. 241, 2008 Mass. App. Div. LEXIS 35, Counsel Stack Legal Research, https://law.counselstack.com/opinion/advanced-spine-centers-inc-v-amica-mutual-insurance-massdistctapp-2008.