BRETT DURANT, оn behalf of himself and all others similarly situated v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, a foreign automobile insurance company
No. 94771-6
IN THE SUPREME COURT OF THE STATE OF WASHINGTON
JUN 07 2018
MADSEN, J.
En Banc
FACTS
This case began with an auto policy claim by plaintiff Brett Durant. Durant has been a policyholder with State Farm Mutual Automobile Insurance Company sinсe 1995 and carried $35,000 in personal injury protection (PIP) coverage. On July 21, 2012, Durant was injured in a motor vehicle accident. He opened a PIP claim with State Farm. State Farm then sent him a “coverage letter” that stated:
The policy provides coverage for reasonable and necessary medical expenses that are incurred within three (3) years of the accident. Medical services must also be essential in achieving maximum medical improvement for the injury you sustained in the accidеnt.
Docket (Dkt.) #30 (Decl. of Brett Durant) at 2 & Ex. C (emphasis added).1
Durant sought treatment with chiropractor Harold Rasmussen, DC, who diagnosed injuries including sprains to the neck, back, pelvis, and right shoulder. After a shoulder MRI (magnetic resonance imaging) showed a ligament sprain and “a possible small type I SLAP [(superior labral anteroposterior)] tear,” Durant was referred to an orthopedic surgeon who diagnosed “mild bursitis/tendinitis,” which was treated with physical therapy and cortisone injections. Id. at 2.
Four months after the accident, State Farm sent Dr. Rasmussen a form letter with blanks to fill in inquiring abоut Durant‘s progress. The letter was directed toward State Farm‘s MMI standard, asking, “Has the patient reached maximum medical improvement?” and “If the patient has not reached maximum medical improvement, what
is your target maximum medical improvement date?” Id. at 2 & Ex. D. Dr. Rasmussen responded that Durant was not at MMI but his target date was “2-1-13.” Id. at Ex. D.
Durant‘s injuries were not resolved by that date, and he continued to receive chiropractic and massage therapy. State Farm then sent another letter to Dr. Rasmussen, which inquired, “You have treated Brett past his given MM[I] date of 2/1/2013. Please explain.” Dkt. #32 (Decl. of Tyler Firkins), Ex. Q at 11 of 13. Dr. Rasmussen replied, “Patient was not stable and needed treatment to 3/27/2013.” Id.
Durant continued to have back, shoulder, and pelvic issues and continued to receive care. His care providers billed his PIP claim as before, but State Farm denied each bill on the basis that, “[s]ervices are not covered, as your provider advised us you previously reached maximum medical improvement.” Dkt. #30, Ex. F.
Durant retained an attorney who wrote to State Farm asking them to pay the outstаnding medical bills. The attorney explained that State Farm must use the standard authorized by
Office of the Insurance Commissioner (OIC) “thoroughly reviews and approves policy language proposed by insurance companies.” Dkt. #30, Ex. H. Durant‘s attorney responded by letter that Durant needed medical treatment from time to time due to exacerbations in order to maintain his recovery and that this treatment should be considered reasonable, necessary, and related under
Durant filed this action in King County Superior Court in 2015, alleging that State Farm‘s use of the MMI standard violates its duty of good faith, breaches the insurance contract, violates the Insurance Fair Conduct Act,
- Does an insurer violate
WAC 284-30-395(1)(a) or(b) if that insurer denies, limits, or terminates an insured‘s medical or hospital benefits claim based on a finding of “maximum medical improvement?”
- Is the term “maximum medical improvement” consistent with the dеfinition of “reasonable” or “necessary” as those terms appear in
WAC 284-30-395(1) ?2
ANALYSIS
First Certified Question: Does State Farm‘s limitation of medical claims based on its MMI provision violate
Durant contends that the plain language of the regulation in question answers the first certified question. We agree.
“Certified questions from federal court are questions of law that this court reviews de novo.” Brady v. Autozone Stores, Inc., 188 Wn.2d 576, 580, 397 P.3d 120 (2017) (citing Carlsen v. Glob. Client Sols., LLC, 171 Wn.2d 486, 493, 256 P.3d 321 (2011)). “This court may reformulate the certified question.” Id. (citing Allen v. Dameron, 187 Wn.2d 692, 701, 389 P.3d 487 (2017)). Further, the meaning of a statute is a question of law that is reviewed de novo. State v. J.M., 144 Wn.2d 472, 480, 28 P.3d 720 (2001). This court‘s fundamental objective in determining what a statute means is to ascertain and carry оut the legislature‘s intent. Id. If the statute‘s meaning is plain on its face, then courts must give effect to its plain meaning as an expression of what the legislature intended. Id. A statute that is clear on its face is not subject to judicial construction. Id.
This court interprets regulations under the rules of statutory construction. Mader v. Health Care Auth., 149 Wn.2d 458, 472, 70 P.3d 931 (2003). It construes the act as a whole, giving effect to all of the language used. Id. If a regulation is unambiguous,
intent can be determined from the language alone, and the court will not look beyond the plain meaning of the words of the regulation. Id. at 473.
We begin with the plain language of the regulation.
(1) Within a reasonable time after receipt of actual notice of an insured‘s intent to file a personal injury protection medical and hospital benefits claim, and in every case prior to denying, limiting, or terminating an insured‘s medical and hospital
benefits, an insurer shall provide an insured with a written explanation of the coverage provided by the policy, including a notice that the insurer may deny, limit, or terminate benefits if the insurer determines that the medical and hospital services: (a) Are not reasonable;
(b) Are not necessary;
(c) Are not related to the accident; or
(d) Are not incurred within three years of the automobile accident.
These are the only grounds for denial, limitation, or termination of medical and hospital services permitted pursuant to
RCW 48.22.005(7) ,48.22.095 , or48.22.100 .
(Emphasis added.) The final sentence of this regulation is unambiguous: an insurer may deny PIP benefits “only” for the reasons listed; no other reasons are permitted.
State Farm argues that its MMI language is merely definitional, explaining the “necessary” provision contained in the regulation. That is unconvincing. First, State Farm‘s policy language and its coverage letter present the MMI provision as an additional criterion that must be met for medical payments. The auto policy provides in relevant part as follows:
Personal Injury Protection Benefits mean accident related:
1. Medical and Hospital Benefits, which are payments for reasonable medical expenses incurred within three years of the date of the accident.
. . . .
Reasonable Medical Expenses mean expenses:
. . . .
2. incurred for necessary:
a. medical, surgical, X-ray, dental, ambulance, hospital, and professional nursing services, and
b. pharmaceuticals, eyeglasses, hearing aids, and prosthetic devices
that are rendered by or prescribed by a licensed medical provider within the legally authorized scope of the provider‘s practice and are essential in achieving maximum medical improvement for the bodily injury sustained in the accident.
Dkt #32, Ex. N at 7 of 24 (some emphasis added).
As presented, “Reasonable Medical Expenses” are defined as fees “incurred for necessary” medical services that are rendered by a medical provider “and are essential in achieving maximum medical improvement for the bodily injury sustained in the accident.” Id. (some emphasis added). Because the MMI provision is stated conjunctively, it is not a definition of “necessary” but is instead a separate and additional prerequisite under the policy for payment of medical expenses. Moreover, the policy‘s introductory provisions explain that “[d]efined words and phrases [contained in the policy] are printed in boldface italics.” Id. at 4 of 24. In the “reasonable medical expenses” quoted passage, “necessary” is not so designated. Thus, the plain language of the auto insurance policy does not support State Farm‘s assertion that its MMI provision defines the term “necessary.”
Further, the coverage letter that Durant received states, in relеvant part, as follows:
MEDICAL AND HOSPITAL BENEFITS
The policy provides coverage for reasonable and necessary medical expenses that are incurred within three (3) years of the accident. Medical services must also be essential in achieving maximum medical improvement for the injury you sustained in the accident. To assist us in determining what expenses are reasonable and necessary, we may obtain a second opinion from a medical provider. We may also have the treatment reviewed by other medical professionals.
Occasionally there are situations where treatment may not be considered reasonable, necessary, or related to the accident. Similarly, there may be cases where the services are not essential in achieving maximum medical improvement for the injury sustained in the accident. In such cases, YOUR PIP COVERAGE MAY
NOT PAY FOR ALL OF YOUR EXPENSES.
Dkt. #30, Ex. C. (emphasis added).
As can be seen, the first sentence in the first paragraph identifies three criteria for receiving medical payments: the medical services must be reasonable, necеssary, and within three years of the accident. The second sentence adds a fourth criterion: the medical services “must also be essential in achieving maximum medical improvement for the injury you sustained in the accident.” Id. (emphasis added). As presented, the fourth criterion is an additional requirement and does not refer back to or define any of the earlier listed criteria.
The second paragraph in the above quoted coverage letter warns that where the listed criteria are nоt met, the insured‘s PIP coverage may not pay for the expenses. Again, the four criteria are separately noted, indicating their separate status as a basis for denying coverage. Neither the policy language nor the coverage letter indicates that the MMI provision is a definition of “necessary” as State Farm contends.
In addition, as Durant‘s circumstance demonstrates, State Farm is using the MMI standard contained in its auto policy as the primary criterion for limiting the responsibility it would otherwisе have to pay medical claims under the regulation; and it is doing so by applying a criterion not listed in the regulation. As noted, the regulation‘s plain language does not permit such additions. “No insurance contract can contain an inconsistent or contradictory term to any mandated, standard provision unless it is more favorable to the insured.” Kroeber v. GEICO Ins. Co., 184 Wn.2d 925, 929-30, 366 P.3d 1237 (2016) (citing
Also, since the regulation‘s terms “reasonable” and “necessary” are not defined, we use their ordinary (dictionary) meaning. See Boeing Co. v. Aetna Cas. & Sur. Co., 113 Wn.2d 869, 877, 784 P.2d 507 (1990) (undefined terms in insurance contracts “must” be given their plain, ordinary, and popular meaning, and courts may look to
standard English language dictionaries to determine common meaning).3 Statе Farm‘s MMI standard is clearly more restrictive than what would ordinarily be considered reasonable and necessary medical care. As Durant‘s case demonstrates, treatment prescribed by his provider to address his ongoing pain resulting from the car accident would be permissible under the plain language of the regulation, which permits such reasonable and necessary treatment. Only State Farm‘s employment of the more restrictive MMI standard disallows such treatments and does so in violation of the regulation.4
urging that the court should defer to the OIC‘s expertise on the issue. This court indeed gives substantial weight to an administrative agency‘s interpretations in its area of expertise, see Port of Seattle v. Pollution Control Hr‘gs Bd., 151 Wn.2d 568, 595, 90 P.3d 659 (2004) (due deference must be given to the specialized knowledge and expertise of an administrative agency), but the view expressed by the OIC is at odds with State Fаrm‘s assertions.
The OIC has filed an amicus brief forcefully stating that it has told carriers, including State Farm, that provisions adding criteria to PIP benefit payments violate
A carrier cannot enforce a policy that denies medicаl and hospital services that are reasonable, necessary, related to the accident, and incurred within three years of the accident, but that do not achieve ‘maximum medical improvement.[‘]
This interpretation of
WAC 284-30-395 has been clearly communicated by the Commissioner, through his staff, to American Family Insurance in 2010, and again to State Farm in 2015, when taking exception to the language in their policies. In both instances, the Commissioner has directed carriers with non-compliant policy forms to submit new policy forms, with language that reflects the limited grounds available for the denial, limitation, or termination of medical and hospital benefits found inWAC 284-30-395(1) . At no point has the Commissioner, or his staff, communicated a contrary interpretation ofWAC 284-30-395(1) . Based on the plain language ofWAC 284-30-395(1) , no carrier can use additional requirements, including “maximum medical improvement” as a basis for denying, limiting, or terminating medical and hospital coverage under PIP.
Id. at 11-12 (emphasis added). The OIC amicus brief concluded that the answer to the first certified question is yes. Id. at 12. For the reasons discussed above, we agree.
Second Certified Question: Is the term “maximum medical improvement” consistent with the definitiоn of “reasonable” or “necessary” as those terms appear in
We answer this certified question no. Washington statutes mandate that insurers writing automobile insurance offer PIP coverage, which includes coverage for payment of “all reasonable and necessary expenses incurred . . . for injuries sustained as a result of an automobile accident.”
the accident. This regulation and the noted statutes reflect Washington‘s strong public policy in favor of the full compensation of medical benefits for victims of road accidents.
By contrast, State Farm‘s policy language limits payment of PIP medical benefits to services “essential in achieving maximum medical improvement.” Dkt. #32, Ex. N at 7 of 24. This limitation denies Durant his PIP medical benefits necessary to return him to his pre-injury state. Excluding payment for palliative care from the reasonable and necessary medical expenses that are required to be paid under PIP coverage violates the public policy reflected in the statutory and regulatory scheme underlying PIP coverage, which is to fully compensate insureds for their actual damages from automobile accidents. See Sherry, 160 Wn.2d at 620-21 (“Washington State has long favored full cоmpensation for those injured in automobile accidents.“). State Farm‘s MMI provision is not consistent with the terms “reasonable” and “necessary” as those terms are used in
Defendant State Farm does not convincingly argue otherwise. It analogizes its MMI provision to the industrial insurance context and to maritime law, which are both distinguishable. State Farm cites a WAC regulation promulgated under Title 51 RCW, the Industrial Insurance Act (IIA), defining “proper and necessary” health care services, that states, “Once a worker‘s сondition has reached maximum medical improvement, treatment that results only in temporary or transient changes is not proper and necessary.”
medical improvement, are not “necessary” services under its PIP policy or
Washington‘s public system of workers’ compensation is not the equivalent of insurance. See Wash. Ins. Guar. Ass‘n v. Dep‘t of Labor & Indus., 122 Wn.2d 527, 532-33, 859 P.2d 592 (1993). The IIA was the product of a “grand compromise” in 1911, in which injured workers were ensured a swift, no-fault compensation system for injuries on the job and employers received immunity from civil suits by workers. Birklid v. Boeing Co., 127 Wn.2d 853, 859, 904 P.2d 278 (1995). As a result, “employees may receive less than full tort damages in exchange for the expense and uncertainty of litigation.” Minton v. Ralston Purina Co., 146 Wn.2d 385, 390, 47 P.3d 556 (2002).
MMI in Title 51 RCW is related to the concept of fixed impairment, which plays a key role in the compromise reflected in the IIA. “Maximum medical improvement may be present though there may be fluctuations in levels of pain and function. . . . ‘Maximum medical improvement’ is equivalent to ‘fixed and stable.‘”
MMI functions in two complementary ways in the workers’ compensation system. First, it establishes that an injured worker has a “fixed and stable” impairment, thereby triggering disability benefits. See id. at 28; see also
By establishing an impairment as fixed and stable, a finding of maximum medical improvement serves a critical role in determining the relative rights and remedies availаble under the IIA, facilitating the “compromise” reflected in that unique statutory scheme.
The restrictive limitation on the definition of “proper and necessary” medical care set forth in the IIA regulation (
The failure to narrow “reasonable” or “necessary” services underscores that the OIC‘s regulation did not adopt the IIA‘s restrictive definition of “proper and reasonable” medical services.
Further, maximum medical improvement in workers’ compensation under state law is closely related to the concept of “cure” in the “maintenance and cure” doctrine applicable to injured seamen under federal maritime law. See Miller v. Arctic Alaska Fisheries Corp., 133 Wn.2d 250, 268, 944 P.2d 1005 (1997) (recognizing that “[m]aintenance and cure is the maritime analog to land-based industrial insurance paying an injured seaman‘s medical expenses (cure) and compensation in lieu of wages (maintenance) for injuries incurred in service of a ship“); see also Dean v. Fishing Co. of Alaska, 177 Wn.2d 399, 406, 300 P.3d 815 (2013) (noting that a shipowner‘s duty to pay maintenance and cure continues until the seaman reaches the point of maximum medical recovery). State Farm agrees that the “maximum medical cure” standard in maritime law is the equivalent of “MMI,” and states that “[u]nder the ‘maximum medical cure’ standard, a ship owner‘s obligation to pay an injured seaman‘s medical bills ends when he or she has reached a point where ‘future treatment will merely relieve pain and suffering but not otherwise improve the seaman‘s physical condition.‘” Def.‘s Resp. Br. at 34-35 (quoting Lee v. Metson Marine Servs., Inc., 2012 WL 5381803, at *2 (D. Haw. Oct. 31, 2012) (court order) (emphasis added)). But State Farm points to nothing in Washington‘s PIP statutes and regulations, or the underlying public policy, that suggests that required payment for medical services will not include treatment that “will merely
relieve pain and suffering but not otherwise improve [a patient‘s] physical condition.” Id. at 35 (quoting Lee, 2012 WL 5381803, at *2).
In sum, State Farm‘s analogizing to workers’ compensation and maritime law is unconvincing. For the reasons discussed above, State Farm‘s use of the term “MMI” is not consistent with the common meaning of “reasonable” and “necessary” as those terms appear in
We answer the first certified question yes. An insurer violates
We answer the second cеrtified question as follows: under the circumstances of this case, the term “MMI” is not consistent with the terms “reasonable” or “necessary” as those terms appear in
Madsen, J.
WE CONCUR:
Fairhurst, C.J.
Johnson, J.
Owens, J.
Stephens, J.
Wiggins, J.
Gonzalez, J.
Gordon McCloud, J.
Yu, J.
Notes
The common meaning of “necessary” is “of, relating to, or having the character of something that is logically required or logically inevitable or that cannot be denied without involving contradiction.” Id. at 1510.
a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatmеnt available or suitable for the client requesting the service.