Moore v. Allstate Ins. Co.

429 P.3d 1045, 293 Or. App. 690
CourtCourt of Appeals of Oregon
DecidedSeptember 6, 2018
DocketA163085
StatusPublished

This text of 429 P.3d 1045 (Moore v. Allstate Ins. 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
Moore v. Allstate Ins. Co., 429 P.3d 1045, 293 Or. App. 690 (Or. Ct. App. 2018).

Opinion

ORTEGA, P. J.

*692Plaintiff appeals a limited judgment entered in favor of defendant, Allstate Fire and Casualty Insurance Company (Allstate), assigning error to the trial court's grant of Allstate's motion for summary judgment. Plaintiff filed an action to recover personal injury protection (PIP) benefits, and Allstate moved for summary judgment arguing that, as a matter of law, it was not required to pay PIP benefits until plaintiff submitted to an examination under oath (EUO). However, *1047plaintiff asserted that, because Allstate failed to pay or deny the PIP benefits within 60 days of receiving her medical bills as required by ORS 742.524(1)(a),1 she was not required to attend the EUO. The trial court granted Allstate's motion on the grounds that plaintiff's refusal to submit to the EUO was not excused because Allstate did not materially breach the insurance policy by failing to pay PIP benefits within 60 days. For the reasons stated below, we conclude that the trial court did not err in granting Allstate's motion for summary judgment and, therefore, we affirm.

In reviewing the trial court's summary judgment ruling, we view the evidence in the light most favorable to plaintiff (the nonmoving party) to determine whether there are genuine issues of material fact that preclude summary judgment and whether defendant was entitled to judgment as a matter of law. ORCP 47 C; Hinchman v. UC Market, LLC , 270 Or. App. 561, 566, 348 P.3d 328 (2015). We state the facts consistently with that standard and, because most of the facts relating to plaintiff's motor vehicle liability insurance with Allstate are intertwined with PIP liability coverage under ORS 742.520 and ORS 742.524, we discuss the facts and the statute together.

Through a liability insurance policy, Allstate provided plaintiff with PIP benefits coverage and promised to *693pay, among other things, medical and hospital expenses if the injury was caused by a motor vehicle accident. While driving, plaintiff was in a car accident on January 16, 2015, in which the other driver accepted fault. Under ORS 742.520(4), an insurer is required to pay all PIP benefits "promptly after proof of loss has been submitted to the insurer," and plaintiff submitted a notice of loss to Allstate on January 21. Because plaintiff informed Allstate that there was a passenger in the car, Allstate sent letters to both plaintiff and her passenger, with PIP applications attached, to obtain the necessary documentation to process their claims.

Plaintiff submitted some of her medical bills on August 3, and Allstate acknowledged receipt of them but stated that payment was "pended for further investigation while outstanding issues [were] resolved." Plaintiff, through her attorney, submitted a letter dated August 26, listing the total amount of medical expenses, and she attached a signed PIP application along with copies of the medical bills she had submitted previously. Allstate suspected that plaintiff was actually alone in her car at the time of the accident and, on October 1, requested that plaintiff submit to an EUO to allow for further investigation of her claims, a request that was consistent with the provision in plaintiff's policy stating that Allstate "may also require any person making [a PIP] claim to submit to examinations under oath." Plaintiff refused that request. In a letter to Allstate, plaintiff contended that Allstate had breached its duty to pay the PIP benefits promptly as required by ORS 742.520(4) and ORS 742.524(1)(a) and, therefore, she was not obligated to submit to the EUO. She then filed this action for breach of the insurance contract on October 19. In response, Allstate filed a motion for summary judgment on the grounds that plaintiff could not assert a claim for breach because, by refusing to submit to an EUO, plaintiff was not in "full compliance with all the terms of the policy."

Under ORS 742.524(1)(a), medical bills are "presumed to be reasonable and necessary unless the provider is given 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." Thus, the statute creates a *694rebuttable presumption for PIP claims, which the Supreme Court explained in Ivanov v. Farmers Ins. Co. , 344 Or 421, 429, 185 P.3d 417 (2008) :

"[T]he presumption established by the legislature in ORS 742.524(1)(a) attaches to PIP claims at their inception and, once *1048established, functions as any other civil presumption, i.e. , it shifts the burden of proof to the party against whom it is directed-in this case, the insurer. That means that the legislature intended that, under ORS 742.524(1)(a), the presumption would operate as follows: When a healthcare provider submits a PIP claim for medical expenses on behalf of an insured, the expenses are presumed to be reasonable and necessary. An insurer may issue a timely denial of a claim to a provider and, once it does so, the expenses are no longer entitled to that presumption."

At the summary judgment hearing, Allstate argued that under the policy and our case law, Allstate had a right to conduct an EUO before plaintiff could assert a claim for breach of contract. Plaintiff argued in response that she was not required to attend the EUO because Allstate had already breached its duty to pay the PIP benefits. In plaintiff's view, when Allstate received her medical bills on August 3, 2015, ORS 742.524

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Related

Ivanov v. Farmers Insurance
185 P.3d 417 (Oregon Supreme Court, 2008)
Wright v. State Farm Mutual Automobile Insurance
196 P.3d 1000 (Court of Appeals of Oregon, 2008)
Hinchman v. UC Market, LLC
348 P.3d 328 (Court of Appeals of Oregon, 2015)
McBride v. State Farm Mutual Automobile Insurance Co.
386 P.3d 679 (Court of Appeals of Oregon, 2016)

Cite This Page — Counsel Stack

Bluebook (online)
429 P.3d 1045, 293 Or. App. 690, Counsel Stack Legal Research, https://law.counselstack.com/opinion/moore-v-allstate-ins-co-orctapp-2018.