Ivanov v. Farmers Insurance

185 P.3d 417, 344 Or. 421, 2008 Ore. LEXIS 278
CourtOregon Supreme Court
DecidedMay 8, 2008
DocketCC 9910-10826; CA A123043; SC S054199
StatusPublished
Cited by17 cases

This text of 185 P.3d 417 (Ivanov v. Farmers Insurance) is published on Counsel Stack Legal Research, covering Oregon Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ivanov v. Farmers Insurance, 185 P.3d 417, 344 Or. 421, 2008 Ore. LEXIS 278 (Or. 2008).

Opinions

[424]*424DE MUNIZ, C. J.

This case involves Oregon’s Personal Injury Protection (PIP) statutes, ORS 742.518 to 742.540. Plaintiffs initiated this case by filing what they initially styled as a class action against defendant insurance companies (Farmers), seeking payment of PIP-related medical expenses that Farmers had denied. Plaintiffs also sought a declaratory judgment holding that “Farmers may not deny [PIP] benefits to its insureds solely on the basis of generalized criteria not specific to claimants’ injuries,” and that “Farmers may not deny [PIP] benefits to [its] insureds * * * unless [the] determination is based on a contemporaneous physical examination [IME] of the insured by a physician selected by Farmers.” In response, Farmers filed a “Motion for Summary Judgment and Memorandum in Opposition to Plaintiffs’ Motion for Class Certification.”1

In its summary judgment motion, Farmers did not address plaintiffs’ claims that, in using generalized preplanned criteria not specific to each claimant, Farmers’ claim review process breached its insurance contracts and violated the PIP statutes. Instead, Farmers argued that: (1) under ORS 742.524, insureds such as plaintiffs, whose PIP claims had been timely denied, had the burden of proving that their claims were medically necessary before their challenge to Farmers’ claims review process could proceed to a trier of fact, and (2) plaintiffs had failed to produce sufficient medical opinion evidence on that issue in response to Farmers’ summary judgment motion. In opposing summary judgment, plaintiffs argued that Farmers’ denials of their PIP claims were based on generalized criteria that (1) were not specific to the insured’s injuries; (2) were not based on an IME; and (3) in any event, involved bills for medical charges that were presumed to be medically reasonable and necessary at the time they were submitted, thus allowing the medical bills themselves to provide the evidence needed for plaintiffs’ case to proceed to a determination on the merits.

The trial court subsequently granted Farmers’ summary judgment motion and disposed of all of plaintiffs’ [425]*425claims. The trial court concluded that, “[as] a matter of law the PIP statutes do not require a contemporaneous medical examination [IME] of the insured prior to the denial of any claim” and that, in any dispute over the payment of a PIP claim, “the insured bears the burden of [proving that their medical expenses are medically reasonable and necessary].” On appeal, the Court of Appeals affirmed, albeit on narrower grounds. It held that, as a predicate to challenging Farmers’ claims review process, plaintiffs were required to prove that their PIP expense claims were medically reasonable and necessary and that, in the absence of expert medical opinion, plaintiffs had failed to produce “evidence from which a trier of fact could infer that the claimed expenses were necessarily incurred).]” Ivanov v. Farmers Ins. Co., 207 Or App 305, 317, 140 P3d 1189 (2006). We allowed plaintiffs’ petition for review and, for the reasons explained below, reverse the decision of the Court of Appeals and the judgment of the trial court.

In reviewing a grant of summary judgment, we view the facts from the summary judgment record and all reasonable inferences that we may draw from them in the light most favorable to the nonmoving party — in this case, plaintiffs. Oregon Steel Mills, Inc. v. Coopers & Lybrand, LLP, 336 Or 329, 332, 83 P3d 322 (2004). In accordance with that methodology, the record establishes that plaintiffs are Oregon residents who each purchased automobile insurance policies from Farmers and were subsequently involved in automobile accidents. Because of those accidents, plaintiffs each submitted claims for their respective medical expenses under the PIP provisions of their policies and Farmers denied those claims.

As a result of those claim denials, plaintiffs filed this action against Farmers, alleging that the process underlying Farmers’ denial of their PIP-related medical claims constituted breach of contract, fraud, breach of the implied covenant of good faith, tortious breach of the duty of good faith, and intentional interference with contractual relations.2 Specifically, plaintiffs alleged that Farmers had failed to inform [426]*426its insureds that, as part of an undisclosed cost containment policy, Farmers had made a business determination to employ computerized billing or file review services as a way to justify the denial of otherwise valid claims for PIP benefits. According to plaintiffs’ complaint, Farmers knew that the review services it employed used automatic medical cost containment software based on generalized, preplanned criteria not specific to a claimant’s particular injuries. Farmers’ goal in using such review services, plaintiffs asserted, was to avoid full reimbursement of otherwise “reasonable and necessary” medical expenses.3 In addition to money damages, plaintiffs’ complaint also sought declaratory relief prohibiting Farmers from denying medical treatment claims based on generalized criteria not specific to a claimant’s injuries and on determinations that specific treatments were not medically necessary, unless those determinations were made by an examining physician.

As previously noted, Farmers moved for summary judgment on all of plaintiffs’ legal claims, contending that the overriding question presented by plaintiffs was a question of law that could be resolved under ORS 742.524(l)(a). In moving for summary judgment, Farmers did not deny that it used the software and protocols just described to decide whether to pay plaintiffs’ claims. Neither did Farmers attempt to establish on the record that its claims review process met contractual and statutory PIP requirements, either as to plaintiffs’ specific claims, or as to general claims for medical expenses like those that plaintiffs made. Farmers argued, instead, that plaintiffs were required to prove the medical reasonableness [427]*427and necessity of their individual claims. However, as we explain below, plaintiffs’ complaint challenged Farmers’ claims review process itself as failing to comply with contractual and statutory PIP criteria, and the issues raised by the complaint thus are logically akin to the issue of whether a specific plaintiffs medical expenses should be covered.

A brief recitation of the purposes and functions of the PIP statutes provides a useful foundation for our analysis. ORS 742.524(1) provides, in part:

“Personal injury protection benefits as required by ORS 742.520 shall consist of the following payments for the injury or death of each person:
“(a) All reasonable and necessary expenses of medical, hospital, dental, surgical, ambulance and prosthetic services incurred within one year after the date of the person’s injury, but not more than $15,000 in the aggregate for all such expenses of the person.

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Ivanov v. Farmers Insurance
185 P.3d 417 (Oregon Supreme Court, 2008)

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Bluebook (online)
185 P.3d 417, 344 Or. 421, 2008 Ore. LEXIS 278, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ivanov-v-farmers-insurance-or-2008.