Essex Chiropractic Office v. Amica Mutual Insurance

2012 Mass. App. Div. 51, 2012 Mass. App. Div. LEXIS 15
Massachusetts District Court, Appellate Division·Decided March 23, 2012·Published·Cited by 2 cases

Opinion

Pierce, J. Plaintiff Essex Chiropractic Office (“Essex”) contends on this appeal

that the trial court erroneously awarded summary judgment to the defendant, Arnica Mutual Insurance Company (“Arnica”), based on a payment made by Arnica to Essex pursuant to Fascione v. CNA Ins. Cos., 435 Mass. 88 (2001). As to both the G.L.c. 90, §34M and the G.L.c. 93A claims, we affirm.

On June 4, 2009, Essex’s patient, Yorvi Matute (“Matute”), was involved in an automobile accident while covered by a standard Massachusetts automobile policy issued by Amica. Matute submitted two applications for personal injury protection (“PIP”) benefits, both accompanied by a health benefit affidavit identifying Mid West National Life Insurance as Matute’s health care provider.

On August 22, 2009, Arnica received a bill for $171.00 from Winchester Emergency Medical for services rendered to Matute on June 4, 2009. That bill was paid with a check dated August 26,2009. On September 4,2009, Arnica received two additional bills for services rendered to Matute. The first, for $584.99, was from Winchester Hospital. The second, for $985.00, was from Essex. Those bills were both paid by checks dated September 17, 2009.

An independent medical examination (“IME”) of Matute was conducted on September 15, 2009 by Dr. John H. Chaglassian (“Chaglassian”). In a report issued the same day, the doctor concluded that Matute had “fully recovered and does not need any additional treatment.” The doctor also stated that Matute had “reached maximum medical improvement and a medical end result.” On September 17,2009, Arnica wrote to Matute reporting the results of the IME and advising him that, based on the IME, Arnica was “terminating all Personal Injury Protection for this accident.” The letter further stated that Arnica would not “consider payment of any bills for treatment received after the date of the [IME].”

On October 1, 2009, Arnica received an invoice from Essex for $1,670.00 for services rendered from September 2 through September 29, 2009. Although some of the treatment was provided before the IME cutoff date, Arnica responded in a letter dated October 6,2009: “We cannot consider payment at this time for the following reason (s): ‘Independent Medical Examination CUT OFF [52]*527/15/2009.’”1 On October 9, 2009, Arnica received an invoice for $218.00 from North Shore Radiological Associates, Inc. for an MRI conducted on July 9, 2009. This invoice was paid with a check dated October 30, 2009. The check was sent by Arnica to Matute’s attorney, Joseph C. Edwards (“Edwards”).

In a statement dated September 1,2009, which Arnica contends it did not receive until on or about October 9,2009, Winchester Hospital sought payment of $3,042.96 for an MRI conducted on July 9, 2009. In response, Arnica sent Attorney Edwards a check, dated November 24, 2009, payable to Winchester Hospital, in the amount of $41.01, with an explanation that Arnica had paid $2,000.00 in PIP benefits under the policy and that “[a] 11 outstanding bills should now be submitted to the health insurer. If the health insurer does not pay the bills in full, they may be re-submitted to Arnica, along with the insurance denial, for consideration.” This language was an apparent reference to the standard Massachusetts automobile insurance policy that, in relevant part, provides that where individuals seeking PIP benefits are covered by a health insurance policy, the PIP insurer “will pay up to $2,000 of medical expenses for any injured person.” The PIP insurer will also pay in excess of $2,000.00, but not more than $8,000.00, for medical expenses not paid by the health plan; however, “[mjedical expenses must be submitted to the health plan to determine what the health plan will pay before [the PIP insurer will] pay benefits in excess of $2,000.” This $2,000.00 limit is referred to in the record as the $2,000.00 PIP “threshold.”

On November 5, 2009, Arnica received from Essex a bill for $865.00 for services rendered between October 1 and October 26, 2009. On November 6, 2009, Arnica sent Essex a form letter denying payment of the bill. As reasons for the denial, the letter had an “X” next to all of the following: “No PIP application on file; Awaiting medical records; Awaiting Health Benefits Affidavit; $2,000 Personal Injury Protection threshold has been reached; Personal Injury Protection Benefits have been exhausted; Independent Medical Examination Cut Off of 9/15/2009; $8,000 Personal Injury Protection benefits have been exhausted; Personal Injury Protection benefits have been denied; and Other.” In its appellate materials, Arnica explains that this letter was the result of “inadvertent error” and the actual reason for the denial was “that the $2,000 PIP threshold had been reached and that the services had been rendered after the IME [cutoff] on September 15, 2009.”

On December 3, 2009, Arnica received a final bill from Essex in the amount of $460.00 for services rendered from November 4 through November 18, 2009. On December 10, 2009, Arnica sent to Essex the same form letter sent on November 6, 2009. This time, the only reason indicated for denying payment was “Independent Medical Examination cut off of 9/17/2009.”2 On February 19, 2010, Essex filed a complaint in the Haverhill District Court alleging violations of G.L.C. 90, §34M, G.L.c. 176D, G.L.c. 93A, and G.L.C. 175, §111C.3

At all relevant times, Richard Harrington (“Harrington”) was a claims supervisor [53]*53at Arnica, responsible for managing litigation involving claims for PIP benefits. In an affidavit in support of Arnica’s motion for summary judgment, Harrington explained that after a March 9,2009 consultation with Colleen Boulette (“Boulette”), the claims adjuster assigned to the Matute case, Arnica had engaged the services of Attorney Charles G. Devine, Jr. (“Devine”). On April 25, 2010, Attorney Devine advised Harrington that legal fees to defend the litigation would be approximately $2,500.00, plus the cost of having Dr. Chaglassian testify at trial. As a result, Harrington “made a business judgment” and decided to pay Essex’s outstanding bills in the total amount of $2,995.00. A check payable to Essex was dated July 16, 2010. Attorney Devine’s cover letter to counsel for Essex was dated September 13,2010. In the letter, Attorney Devine cited Fascione and stated, “As you know, my client’s tender of the full PIP payments extinguishes your client’s claim under M.G.Lc. 90, §34M.” A stipulation of dismissal with prejudice was enclosed with the check. The payment was received by Essex’s counsel on September 15, 2010. The check was never cashed.

While Arnica was conferring internally, consulting with counsel and considering its options, the litigation continued. The parties attended a case management conference on June 11, 2010, exchanged correspondence, had telephone conversations, engaged in discovery, and filed motions with the court, including Essex’s motion to amend the complaint, which was filed the same day that Essex received the Fascione payment. On November 22,2010, Arnica filed its motion for summary judgment. On November 30, 2010, Essex filed a cross motion for summary judgment, which also served as its opposition to Arnica’s motion. On December 21, 2010, the trial court issued an order allowing Arnica’s motion for summary judgment and denying the cross motion. This appeal followed.

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Essex Chiropractic Office v. Amica Mutual Insurance, 2012 Mass. App. Div. 51, 2012 Mass. App. Div. LEXIS 15 (Mass. Ct. App. 2012).

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