Whitworth v. USAA Casualty Insurance Company

District Court, W.D. Washington·Decided June 16, 2021·No. 2:20-cv-00315·Unknown

Opinion

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF WASHINGTON AT SEATTLE KERRY WHITWORTH, CASE NO. C20-0315JLR Plaintiff, ORDER ON MOTION TO v. EXCLUDE AND MOTION FOR USAA CASUALTY INSURANCE COMPANY, Defendant. I. INTRODUCTION Before the court are two motions filed by Plaintiff Kerry Whitworth: (1) a motion to exclude the testimony of Dr. Timothy Chen (MTE (Dkt. # 19)); and (2) a motion for partial summary judgment (MSJ (Dkt. # 20)). Defendant USAA Casualty Insurance Company (“USAA CIC”) opposes both motions. (MTE Resp. (Dkt. # 26); MSJ Resp. (Dkt. # 22).) The court has considered the motions, the submissions in favor of and in // opposition to the motions, the relevant portions of the record, and the applicable law. Being fully advised,1 the court DENIES both motions.

This case centers on the Personal Injury Protection (“PIP”) benefits that Mr. Whitworth filed for after being injured in a car accident. (See Compl. (Dkt. # 1-1) ¶¶ 5-19, 29-44, 52-53.) The court details the relevant factual background before summarizing the procedural background of this matter. A. Factual Background

In April 2018, Mr. Whitworth, his wife, and their granddaughter suffered injuries resulting from a car accident; all three filed PIP claims to USAA CIC under the Whitworths’ policy number 0021 667 02C 7102 7 (the “Policy”). (Evans Decl. (Dkt. # 24) ¶ 4, Ex. 4 at CF_0467-69;2 id. ¶ 1, Ex. 1 (“Policy”); id. ¶ 11.) The Policy allowed PIP medical benefits in the amount of $50,000 per person, per accident. (Policy at

CP_005.) The Policy defined “medical and hospital benefits” as “the medical payment fee for medically necessary and appropriate medical service incurred by or on behalf of the covered person within three years from the . . . automobile accident.” (Id. at CP_024.) It in turn defined “medically necessary and appropriate medical service” as //

1 Mr. Whitworth requests oral argument on both motions (see MTE at 1; MSJ at 1), but the court finds that oral argument would not be helpful in its disposition of the motions, see Local Rules W.D. Wash. LCR 7(b)(4). 2 The exhibits described in Mr. Evans’s declaration are not filed with his declaration and instead are attached to USAA CIC’s response to the motion for partial summary judgment. (See MSJ Resp.; Evans Decl.) “those services . . . provided or prescribed by a licensed hospital, licensed physician, or other licensed medical provider that, as determined by [USAA CIC] or someone on [its] behalf, are required to identify or treat [bodily injury] caused by an auto accident.” (Id.)

Mr. Whitworth subsequently sought treatment at Lynden Physical Therapy for a left shoulder strain, including treatment received on September 28, 2018. (See Courtney Decl. (Dkt. # 21) at 1-2,3 Ex. A; Evans Decl. ¶ 5, Ex. 5 at MEDICAL_3160.) USAA CIC sent the records for this treatment to Auto Injury Solutions (“AIS”), a third-party medical consultant service that evaluates records for medical necessity. (See Evans Decl. ¶ 5, Ex.

5.) Dr. Thomas Albus, an orthopedic surgeon with AIS, found that the physical therapy “service(s) delivered on 9/28/18 was not medically necessary” because the need for such treatment over three months after the accident was not supported. (Id. at MEDICAL_3181.) Dr. Wadih Joseph Absi, another orthopedic surgeon with AIS, completed a “peer appeal” of Dr. Albus’s opinion and reached the same conclusion: The

treatment was not medically necessary because the physical therapy sessions “surpassed the guideline recommended 8-12 visits.” (Id. at MEDICAL_3160.) Thus, Dr. Absi concurred with Dr. Albus that reimbursement should be denied for the physical therapy sessions on September 28, 2018. (Id. at MEDICAL_3160-61.) Finally, Dr. Timothy Chen with AIS also reviewed Mr. Whitworth’s shoulder

injury and concluded that because of the “long delay in [the] first documented report of shoulder pain” of almost four months after the car accident, “causality to the [car 3 Ms. Courtney’s declaration does not have paragraph numbers. (See Courtney Decl.) Thus, the court cites to the applicable page number. accident] cannot be definitively established” for the left shoulder pain. (Id. at MEDICAL_0780.) Based on these physician reviews, USAA CIC initially did not cover the cost of the September 28th physical therapy sessions. (See Courtney Decl. at 1-2,

Ex. A at MEDICAL_3169-70.) USAA CIC additionally utilized a methodology, called the Milliman Reasonable Fee Methodology (“Milliman Methodology”), to evaluate the reasonableness of the billed charge for a medical service. (Mills Decl. (Dkt. # 23) ¶ 5.) The Milliman Methodology looks at a collection of medical service charge data from the United States Department of

Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) for a particular geographic area and calculates a reasonable fee amount “based on the 80th percentile of billed charges for each medical service in each geographic area.” (Id. ¶¶ 2, 16, 21-22.) In other words, for every 1,000 charges in the data, 800 charges are less than or equal to the calculated reasonable fee estimate. (Id.

¶¶ 2, 17, 25.) The methodology, as applied to Mr. Whitworth’s claims, took into account the geographic area of Whatcom County, the type of provider, the medical service provided, the “modifier information” on the bill, the place of service, the number of visits, and when the service occurred. (Id. ¶¶ 7-15.) Mr. Whitworth’s physical therapy billed $65 per unit, but the Milliman Methodology calculated a reasonable fee amount of

$51.22 per unit. (Id. ¶ 50, Ex. 2 at 1.) On June 20, 2019, Lynden Physical Therapy notified Mr. Whitworth that “he needs to look for a new [physical therapy] clinic.” (Courtney Decl. at 2, Ex. C at 1.) A week later, on June 27, 2019, Mr. Whitworth wrote to USAA CIC challenging, amongst other denials, USAA CIC’s refusal to fully cover various physical therapy sessions. (Courtney Decl. at 2, Ex. D (“6/27/19 Letter”) at 5-6.) The parties continued to negotiate various offers. (See Evans Decl. ¶ 4, Ex. 4 at CF_1662-66, CF_2772, CF_2790,

CF_2811-12.) USAA CIC sent a letter on July 8, 2019, offering $75,000 to resolve the claim and asking for a response. (Id. at CF_2790.) On August 2, 2019, USAA CIC again made an offer, this time for $100,000 to settle the claim. (Id. at CF_2882-83.) In September 2019, upon further review, USAA CIC overturned previously declined payments and partially reimbursed Mr. Whitworth for those sessions. (Courtney Decl. at

1-2, Ex. A at MEDICAL_3164-65.) USAA CIC continued to process payments related to Mr. Whitworth’s claim through March 2020—many of which related to denials in Mr. Whitworth’s June 27, 2019, letter—until it reached Mr. Whitworth’s maximum coverage limit of $50,000. (See Evans Decl. ¶ 2, Ex. 2 at 4, 7-8; 6/27/19 Letter at 1-2.) B. Procedural Background

Mr. Whitworth brought suit on October 31, 2019, in state court, asserting, in part, claims for bad faith and violations of the Washington Consumer Protection Act (“CPA”). (See Compl. ¶¶ 29-44, 52-53.) USAA CIC removed this suit to federal court, (see Not. of Removal (Dkt. # 1)), and the parties proceeded to exchange initial disclosures, (see Wilson Decl. (Dkt. # 27) ¶ 1, Ex. 1).4 Mr. Whitworth identified Dr. Chen as a potential

witness “to testify regarding the necessity of the care for [Mr. Whitworth’s] injuries // 4 Again, the exhibits referenced in Mr. Wilson’s declaration are not filed with the declaration and instead are attached to USAA CIC’s response to the motion to exclude. (See MTE Resp.; Wilson Decl.) caused by the collision.” (Id. at 6.) USAA CIC also identified Dr. Chen as a “percipient fact witness with expert qualifications” in response to an interrogatory and identified Dr. Chen’s review reports as related to the handling of Mr. Whitworth’s claim. (Wilson

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Whitworth v. USAA Casualty Insurance Company, (W.D. Wash. 2021).

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