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Gamata v. Allstate Insurance Co.4/28/1999
BURNS, C.J., WATANABE, AND ACOBA, JJ.
We hold that under the Hawaii motor vehicle insurance law, Hawaii Revised Statutes (HRS) chapter 431:10C (1993) (the no-fault law), no-fault benefits are expenses which are appropriate, reasonable and necessarily incurred and are not restricted to treatment characterized as "curative" as opposed to "palliative."
We conclude that when it affirmed denial by Defendant-Appellee Allstate Insurance Company (Allstate) of no-fault coverage for medical treatment sought by Allstate's insured, Plaintiff-Appellant Edwin G. Gamata (Plaintiff), the district court of the first circuit (the court) ruled contrary to the foregoing proposition. Therefore, we vacate the court's March 5, 1998 oral order and the May 1, 1998 judgment to that effect.
We note that after filing his complaint, Plaintiff proceeded with and paid for the contested treatment despite Allstate's denial of coverage. In light of Wilson v. AIG Hawaii Ins. Co., 89 Hawaii 45, 968 P.2d 647 (1998), decided during the pendency of this appeal, we hold, further, that the provider of the treatment, Dr. Bernard Portner (Dr. Portner), and not Plaintiff, is the real party in interest with respect to any action against Allstate for reimbursement of the treatment costs. We instruct, then, that on remand, any payments made by Plaintiff to Dr. Portner must be returned to Plaintiff, and that Dr. Portner may be joined or substituted as a party plaintiff, as the case may be, if he seeks reimbursement from Allstate.
With respect to Plaintiff, we conclude that he may be a real party in interest for the purpose of establishing that the treatment costs should be included in calculating the statutory dollar threshold for bringing an action in tort. See id. at 50, 968 P.2d at 652. Under the circumstances of this case, we direct that on remand Plaintiff shall be afforded leave to amend his pleadings to assert that Allstate's denial jeopardized his right to sue in tort, if he desires to do so.
Finally, in the event that Plaintiff and/or Dr. Portner pursue(s) his or their claim(s) on remand, we conclude that (1) evidence of Dr. Portner's purpose and reasons for recommending the contested treatments would be relevant in determining whether Allstate's denial was proper, and (2) evidence of Plaintiff's post-denial treatment and condition would be relevant to a claim that Allstate's denial was premature.
I.
Plaintiff was involved in a motor vehicle collision on March 28, 1997, in the City and County of Honolulu. Following this accident, Plaintiff received medical treatment from Dr. Portner from April 24, 1997 through, at least, December 19, 1997. Apparently, Allstate paid for the treatment from April 24, 1997 through October 13, 1997 only.
In a "Denial of Claim" form dated October 13, 1997, Allstate informed Plaintiff that he "was not entitled to any benefits under the Hawaii No-Fault Law for the following reason(s): Pursuant to [the independent medical examination (IME) report of Dr. David Sheetz (Dr. Sheetz)] dated September 5, 1997, and the records available in your claim file, your continued complaints are not due to the . . . accident[.]" The form notified Plaintiff that if he "wish to contest this determination," he had, among other options, the right to "bring court action against . . . Allstate[.]"
Dr. Portner subsequently submitted two "treatment plans" to Allstate dated November 3, 1997. The first treatment plan requested a magnetic resonance imaging (MRI) of Plaintiff's cervical spine and was to be administered sometime during the period from November 13, 1997 to December 20, 1997. The second treatment plan requested a "selec
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