Holbrook v. Commerce Insurance

15 Mass. L. Rptr. 510
CourtMassachusetts Superior Court
DecidedNovember 26, 2002
DocketNo. 0100582
StatusPublished
Cited by1 cases

This text of 15 Mass. L. Rptr. 510 (Holbrook v. Commerce Insurance) is published on Counsel Stack Legal Research, covering Massachusetts Superior Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Holbrook v. Commerce Insurance, 15 Mass. L. Rptr. 510 (Mass. Ct. App. 2002).

Opinion

Fecteau, J.

This is an action brought by the plaintiff alleging that the defendant breached its policy of insurance with the plaintiff regarding medical expenses claimed payable due from Personal Injury Protection (“PIP”) coverage under her Massachusetts automobile insurance policy, as well as damages under the provisions of G.L.c. 93A and c. 176D for the defendant’s refusal to pay those benefits. The defendant contends that it owes no further payments to or on behalf of the plaintiff due to her failure to comply with a contractual and statutory responsibility, after payment by Commerce of the first $2000.00 in PIP benefits, to submit all medical bills to her health insurer. Additionally, the defendant contends that it is no longer obligated to pay such benefits as they would duplicate payments from the tortfeasor that were ordered as a result of voluntary and binding arbitration.

On November 19,2002, this matter came on for trial before me, sitting without jury, the parties having waived their rights thereto. Upon consideration of the evidence, including extensive agreed statements of fact, the following findings of fact and rulings of law are made.

FINDINGS OF FACT

1. On November 27, 1998, the plaintiff, then insured by the defendant (“Commerce”) under a Massachusetts policy of automobile insurance coverage, 6th edition, was injured as a result of a motor vehicle accident. She was brought by ambulance to the Clinton Hospital and was treated in the emergency room. Thereafter, she sought and received medical treatment from various providers. She was at that time and until August 1, 1999, also insured under a policy of health insurance with the Tufts Health Plan.

2. She notified Commerce of the accident on November 30, 1998 and an application for Personal Injury Protection benefits was sent to the plaintiff on or about December 4, 1998, along with a request for health insurance information. A second application was sent to plaintiffs counsel on or about January 5, 1999. On February 12, and March 12, 1999, Commerce wrote to plaintiff s counsel to request a return of a completed PIP application form.

3. On or about March 22, 1999, the plaintiff sent to Commerce the completed PIP form along with medical bills that totaled $3639.00, and reports from medical providers. She provided to Commerce no information regarding whether the plaintiff was covered by a health insurance policy but on the same date, the plaintiff, through her attorney, submitted the same medical bills to Tufts. On March 30, 1999, the defendant issued payments under PIP coverage which totaled $2000.00, payable to New England Chiropractic, in the amount of $1765.00 and $235.00 to the Town of Colchester for ambulance services.

4. On April 9, 1999, the defendant caused the plaintiff to undergo a physical examination with a medical doctor, a result of which was a letter to the plaintiff through her counsel that Commerce would deem her at a medical end result as of April 22, 1999, thus allegedly ending their liability for PIP benefits. In any event, it had paid up to the limit of the first plateau of benefits and intended to await further information concerning the plaintiffs health insurer and its treatment of the medical bills that remained unpaid.

5. On August 13, 1999, Tufts Health Plan generated and sent to the plaintiff a document called an “itemization of charges received.” This showed medical bills of the plaintiff that had been submitted from Clinton Hospital, Central Mass. Magnetic Imaging and MRI of Worcester. This document was not an explanation of benefits, nor did it address the chiropractic bill sent by the plaintiffs attorney.

6. Commerce did not receive any further information concerning the plaintiffs claim for PIP benefits or about her health insurance until January 20, 2000, at which time she submitted to Commerce medical [511]*511bills which totaled $6234.87. The defendant thereupon requested the plaintiff to submit an explanation of the action taken by her health insurer on the medical bills sent to Tufts Health Plan. Neither the plaintiff, nor Tufts ever provided to Commerce any confirmation that the bills that the plaintiff complains that it unlawfully refused to pay were ever submitted to Tufts or any explanation as to how Tufts handled any bills submitted. In fact, while the plaintiff had submitted the bill from New England Chiropractic to Tufts, the health insurer had a policy that required the submission of medical bills to be submitted by the provider and not the insured, or her attorney, unless reimbursement was sought. There is no evidence that Tufts acted in any way upon the attorney’s submission of bills for payment, including that of New England Chiropractic.

7. It is uncontroverted that the plaintiffs health insurance coverage provided by Tufts Health Plan excluded payment for spinal manipulation services and would have fully rejected such a claim for payment, had such a claim been presented. Such a rejection would have resulted in the transmission of an “explanation of benefits” form to the insured. Had such a form been sent to the plaintiff, and received by Commerce, the defendant would have been required to pay for such services under the PIP coverage, assuming causal relationship existed, subject to other contract provisions. At no relevant time was Commerce in possession of the plaintiffs health insurance plan with Tufts nor had Tufts ever informed Commerce of the exclusion of chiropractic services from its coverage.

8. Part 2 of the plaintiffs auto policy with the defendant reads, in relevant part, as follows: “(s]ome people have a policy of health, sickness, or disability insurance or a contract or agreement with a group, organization, partnership or corporation to provide, pay for, or reimburse the cost of medical expenses. If so, we will pay up to $2000.00 of medical expenses for any injured person. We will also pay medical expenses in excess of $2000.00 for such injured person which will not be paid by a medical expense provider. In either case, our total payment for medical expenses, lost wages and replacement services will not exceed $8000.00.” At p. 6. Part 2 of the policy also states that: “(w]e will not pay PIP benefits to or for an injured person, to the extent those benefits would duplicate expenses or losses recovered by that person in a court judgment or settlement.” At p. 7.

9. On January 25, 2001, the tort claim between the plaintiff and the adverse motor vehicle operator was submitted to voluntary and binding arbitration, in which the arbitrator found that all of the damages incurred by the plaintiff amounted to $15,900.00, from which $2000.00 was deducted as representing the amount exempted from such an award on account of no-fault, PIP benefits paid. During said arbitration hearing, all of the plaintiff s medical expenses incurred were submitted into evidence on the issue of damages. The arbitration award was general in nature, and it neither delineated among the traditional elements of damages nor were medical expenses, in full or in part, excluded from consideration by the arbitrator on the issue of damages.

DISCUSSION

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Related

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18 Mass. L. Rptr. 643 (Massachusetts Superior Court, 2004)

Cite This Page — Counsel Stack

Bluebook (online)
15 Mass. L. Rptr. 510, Counsel Stack Legal Research, https://law.counselstack.com/opinion/holbrook-v-commerce-insurance-masssuperct-2002.