McBride v. State Farm Mutual Automobile Insurance Co.

386 P.3d 679, 282 Or. App. 675, 2016 Ore. App. LEXIS 1523
CourtCourt of Appeals of Oregon
DecidedDecember 7, 2016
Docket131115747; A159232
StatusPublished
Cited by3 cases

This text of 386 P.3d 679 (McBride v. State Farm Mutual Automobile Insurance Co.) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
McBride v. State Farm Mutual Automobile Insurance Co., 386 P.3d 679, 282 Or. App. 675, 2016 Ore. App. LEXIS 1523 (Or. Ct. App. 2016).

Opinion

SHORR, J.

Plaintiff appeals a judgment entered after the trial court granted summary judgment in favor of defendant State Farm Mutual Automobile Insurance Company (State Farm). Plaintiff assigns error to the trial court’s grant of summary judgment to State Farm and its denial of plaintiffs cross-motion for partial summary judgment. For the reasons that follow, we conclude that the trial court neither erred in granting State Farm’s motion for summary judgment nor in denying plaintiffs cross-motion for partial summary judgment. Accordingly, we affirm.

Most of the facts material to our analysis are undisputed.1 Because some of the facts relating to plaintiffs motor vehicle liability insurance contract with State Farm are inextricably tied to the Oregon statutes that require a motor vehicle insurer to provide personal injury protection (PIP) benefits with liability coverage, we discuss both the facts and the relevant Oregon PIP statutes together.

Plaintiff purchased motor vehicle liability insurance from State Farm. Oregon law requires that “[e]very motor vehicle liability policy issued for delivery in this state that covers any private passenger motor vehicle shall provide personal injury protection benefits” to the insured, among other persons. ORS 742.520(1). PIP benefits include benefits for the “injury or death” of a person resulting from the “use, occupancy or maintenance” of, with limited exceptions, “any motor vehicle.” ORS 742.520(2). Those benefits include, as relevant here, “[a]ll reasonable and necessary expenses of medical *** services incurred within two years after the date of the person’s injury, but not more than $15,000 in the aggregate for all such expenses of the person.” ORS 742.524(l)(a).2

Oregon law requires that “[a]n insurer shall pay all personal injury protection benefits promptly after proof [678]*678of loss has been submitted to the insurer.” ORS 742.520(4). Thus, the PIP statutes were created “to provide, promptly and without regard to fault, reimbursement of some out-of-pocket losses resulting from motor vehicle accidents.” Perez v. State Farm Mutual Ins. Co., 289 Or 295, 300, 613 P2d 32 (1980).

The Oregon legislature has provided certain presumptions regarding PIP benefit claims. As relevant here, medical expenses are “presumed to be reasonable and necessary unless the [medical] provider receives notice of denial of the charges not more than 60 calendar days after the insurer receives from the provider notice of the claim for the services.” ORS 742.524(l)(a). If an insurer denies payment of PIP benefits, the insurer has a duty to “[p]rovide written notice of the denial, within 60 calendar days of receiving a claim from the provider, to the insured” and must explain the reasons for the denial and the method for contesting the denial. ORS 742.528(1). The insurer must also provide a copy of the notice of the denial to the medical provider within the same 60-day time frame. ORS 742.528(2).

As mandated by Oregon law, State Farm’s motor vehicle liability insurance policy provided PIP benefit coverage to plaintiff. State Farm’s policy promised that

“[w]e will pay personal injury protection benefits in accordance with the [Oregon] Personal Injury Protection Act for bodily injury to an insured caused by accident resulting from the occupancy, maintenance or use of a motor vehicle.”

(Emphasis and boldface omitted.)3 The policy also provided that State Farm reserved the right to use a medical examination of any injured person to determine if: “(1) the bodily injury was caused by a motor vehicle accident; and (2) the expenses incurred are reasonable medical expenses for the bodily injury sustained [.] ” (Emphasis and boldface omitted.) In other words, State Farm reserved the right to compel a medical examination of an injured person to determine, [679]*679among other things, whether it believed the injured person’s medical expenses were reasonable and necessary.

While insured by State Farm, plaintiff was in an automobile accident on November 23, 2011. Plaintiffs vehicle was struck in the rear by a second vehicle, which, in turn, had been rear-ended by a third vehicle that had pushed the second vehicle forward into plaintiffs vehicle. As a result of her accident, plaintiff sought medical and physical therapy services and submitted the resulting expenses to State Farm for reimbursement. Plaintiff submitted and was reimbursed for medical expenses up until June 2012.

On July 12, 2012, a State Farm claims representative responsible for Oregon PIP benefits called plaintiff to set up a medical examination in accordance with the policy requirements to assess the medical expenses that plaintiff submitted in June. The representative felt that a medical examination was appropriate to determine whether plaintiff was still incurring reasonable and necessary medical expenses from the accident because of a gap in her medical treatments, the type of treatment that was resumed, the length of time she was previously treated, and the nature of the impact of the accident. The representative told plaintiff that State Farm would be unable either to pay or deny plaintiffs pending PIP claims as of June 2012 until State Farm received the results of the medical examination.

The medical examination was scheduled for August 10, 2012, but plaintiff failed to show up for it.4 Plaintiff later testified that she did not know why she did not show up for the examination, but she had made the decision not to attend. On August 10, after plaintiff failed to attend the examination, the State Farm representative called plaintiff and discovered that she was now represented by an attorney. State Farm called plaintiffs attorney on August 21, August 29, September 13, and October 15 to try to reschedule the medical examination. Plaintiffs attorney’s office assistant and paralegal received and noted State Farm’s incoming phone [680]*680messages, but an attorney never responded to set up an appointment. Plaintiff never participated in State Farm’s requested medical examination.

State Farm refused to pay the medical bills pending from June 2012 and after. The claims representative testified that he denied the bills because of plaintiffs failure to cooperate with the compelled medical examination and State Farm’s inability to determine that the bills “met the criteria of reasonable and necessary” expenses. Significant to our analysis, State Farm did not send a timely written denial of plaintiffs PIP claims to the insured within 60 days of receipt of the claims as required by ORS 742.528.

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Related

Moore v. Allstate Ins. Co.
429 P.3d 1045 (Court of Appeals of Oregon, 2018)
Shaban v. State Farm Fire & Casualty Co.
398 P.3d 507 (Court of Appeals of Oregon, 2017)

Cite This Page — Counsel Stack

Bluebook (online)
386 P.3d 679, 282 Or. App. 675, 2016 Ore. App. LEXIS 1523, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mcbride-v-state-farm-mutual-automobile-insurance-co-orctapp-2016.