Austin v. Illinois Farmers Insurance

815 N.E.2d 435, 351 Ill. App. 3d 931, 287 Ill. Dec. 32, 2004 Ill. App. LEXIS 971
CourtAppellate Court of Illinois
DecidedAugust 17, 2004
Docket5-03-0579
StatusPublished
Cited by2 cases

This text of 815 N.E.2d 435 (Austin v. Illinois Farmers Insurance) is published on Counsel Stack Legal Research, covering Appellate Court of Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Austin v. Illinois Farmers Insurance, 815 N.E.2d 435, 351 Ill. App. 3d 931, 287 Ill. Dec. 32, 2004 Ill. App. LEXIS 971 (Ill. Ct. App. 2004).

Opinion

JUSTICE KUEHN

delivered the opinion of the court:

This appeal stems from the trial court’s August 21, 2003, order denying the defendant’s motion to compel arbitration and to stay the plaintiff’s claims. The arbitration provision at issue provides as follows:

“If an insured person and we do not agree[ ] (1) that the person is entitled to recover for medical services, (2) that the medical services are a result of a covered accident, or (3) as to the nature, frequency, or cost of the medical services, either that person or we may demand that the issue be determined by arbitration.
The arbitrator shall determine (1) if the medical services are as a result of a covered accident, (2) if the medical services incurred are reasonable expenses and necessary medical services, and (3) the amount of any payment under this part as determined by this policy.”

The trial court, ruling from the bench, essentially concluded that the arbitration clause at issue was unenforceable because the claims raised by the plaintiff were different from those referenced in the arbitration clause. The court also found that arbitration would be cost-prohibitive. The defendant’s appeal is before this court pursuant to Supreme Court Rule 307(a)(1) (188 Ill. 2d R. 307(a)(1)), because the motion that was denied sought injunctive relief.

FACTS

On December 23, 1996, Ola Austin (the plaintiff) was in a motor vehicle accident in which she sustained bodily injuries. At the time of the accident, the plaintiff was insured under an automobile policy issued by defendant Illinois Farmers Insurance Company (Farmers). The standard policy contained a medical-payments-coverage section. She sought and received chiropractic treatment, beginning on January 13, 1997. For some reason, her chiropractic physician did not include an initial examination and diagnosis in the plaintiffs records. The first mention of the plaintiffs condition did not occur until March 17, 1997, at which time he diagnosed her with a mild cervical sprain/ strain. The plaintiff was seen by her chiropractor a total of 61 times over the course of 71 weeks. She turned the associated medical bills in to Farmers for payment pursuant to the medical-payments coverage.

The medical-payments-coverage section of the policy stated that Farmers would pay “reasonable” expenses for “necessary” medical services furnished within two years from the date of an accident “arising from” the use of the insured automobile that resulted in “bodily injury.” “Necessary medical services” are defined as “medical services which are usual and customary for treatment of the injury, including the number or duration of treatments, in the county in which those services are provided,” and which are “necessary for the treatment of the injury.” The policy defines “reasonable expenses” as those that are “usual and customary for necessary medical services in the county in which those services are provided.”

Additionally, the policy provides that Farmers has the authority to submit claims for medical expenses to outside evaluation services:

“At our expense, we may employ or enter into contract with an independent medical consultant(s) to assist us in determining whether all or any portion of any claim is for reasonable expenses or necessary medical services. We may submit to such consultant any medical records, reports, bills, statements, results of tests and examinations, and any other documentation or material we deem appropriate.”

Pursuant to that provision, Farmers submitted the plaintiffs medical file to Terrance Flanagan, D.C. Dr. Flanagan found problems with the documentation of the plaintiffs diagnosis and care. Specifically, Dr. Flanagan noted that given the diagnosis, the plaintiffs course of care should only have endured for about one month and would not have required treatment as frequent as that the plaintiff received. Dr. Flanagan also found fault with ongoing documentation in the plaintiffs progress record. He concluded that the plaintiffs injury should have been resolved on or about March 10, 1997, and that ongoing care was more like maintenance in nature. Maintenance type of care would not “be considered essential to treatment of the injuries” the plaintiff had received. Dr. Flanagan recommended that Farmers deny the charges for the plaintiffs care after March 10, 1997.

Dr. Flanagan did not examine the plaintiff and based his opinions solely upon the records review he was hired to perform.

As a result of Dr. Flanagan’s recommendations, Farmers declined to reimburse the plaintiff for any expenses for treatment after March 10, 1997.

Nearly three years later, the plaintiff filed suit against Farmers on behalf of herself and a putative class of insureds. Counts I and II were for breach of contract and alleged that Farmers failed to pay all the plaintiffs “reasonable and necessary” medical expenses. The plaintiff alleges that Farmers hired a biased medical reviewer and that, as a direct result of this biased review, not all the plaintiffs medical bills had been properly reimbursed. Count III of her complaint alleged a violation of the Consumer Fraud and Deceptive Business Practices Act (815 ILCS 505/1 et seq. (West 2000)). She claimed compensatory damages of $2,852, representing the amount of medical expenses that Farmers refused to pay.

In response to the complaint, Farmers gave the plaintiff written notice of its intent to invoke the binding arbitration clause contained within its insurance policy. Farmers filed a motion to compel arbitration. In addition to the arbitration clause, Farmers’ policy also indicated that no legal action could be taken against it “unless there is full compliance with all the terms of this policy.”

Thereafter, the plaintiff amended her complaint, alleging that the arbitration provision was unenforceable because it was a part of an alleged fraudulent scheme and because it could be used to prevent the plaintiff from effectively vindicating her statutory and common law claims since the costs of arbitration would likely exceed the disputed amount.

On August 21, 2003, the circuit court held its hearing on Farmers’ motion to compel arbitration. At the conclusion of the hearing, the trial judge denied the motion. The court’s written order does not indicate its reasoning. At the conclusion of the hearing, the trial court stated as follows:

“[I]t seems to me that the complaint clearly sets out this as being the wrong, that a party is injured, has medical bills. He first submits those to the company for payment. In that initial process the company uses these biased reports as part of the fraudulent scheme to say that [‘]we are not going to pay all of your bills, we are going to pay some amount less, which is some amount less than what you’ve asked for.f] Then as part of the scheme they’ve put in the arbitration clause, and the company now says[J [‘][F]or you to determine this as to who is right and who is wrong, you must go to arbitration, but the way we have set this up, the arbitration will cost you more than what the initial dispute is.[’] I think that’s four square with the other cases.

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815 N.E.2d 435, 351 Ill. App. 3d 931, 287 Ill. Dec. 32, 2004 Ill. App. LEXIS 971, Counsel Stack Legal Research, https://law.counselstack.com/opinion/austin-v-illinois-farmers-insurance-illappct-2004.