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Gamata v. Allstate Insurance Co.4/28/1999
, in relevant part, that "every person insured under [the no-fault law], . . . suffering loss from accidental harm arising out of the operation, maintenance, or use of a motor vehicle, has a right to no-fault benefits." (Emphasis added.) "Accidental harm" means "bodily injury . . . caused by a motor vehicle accident to a person." HRS § 431:10C-103(1) (emphasis added). No-fault benefits are defined under HRS § 431:10C-103(10)(A)(i) and (ii) to include " ll appropriate and reasonable expenses necessarily incurred for medical" and other services. (Emphasis added.) HRS chapter 431:10C provides that an insurer's denial of benefits may, at the claimant's option, be reviewed in an administrative hearing, an arbitration proceeding, or a civil trial. See supra note 4.
Under the foregoing statutes, Plaintiff had a right to bring a civil action against Allstate for its coverage denial and the court was required to determine (1) whether Plaintiff's injuries were "caused by" the accident, and (2) if so, whether Dr. Portner's treatment of Plaintiff resulted in "appropriate and reasonable expenses necessarily incurred." HRS § 431:10C-103(1), (10)(A)(i) and (ii).
A.
We believe that the court adopted Allstate's third defense theory, that is, that it should apply a recovery standard to Dr. Portner's treatment in consonance with the Yucoco order. The court focused on Plaintiff's testimony that the treatment supplied only "temporary relief" and "questioned" Dr. Portner's treatment plan because his services "only provided temporary relief." The court inferred that this " not show a pattern of improvement[.]"
According to Allstate, the third defense theory was applicable if the court found that "Plaintiff's condition was attributable to the subject accident." Consistent with this approach, the court made no express finding that Plaintiff's injuries were not caused by a motor vehicle accident. Thus, we surmise the court found Plaintiff had suffered injuries caused by the accident, but that Dr. Portner's treatment approach had not satisfied the Yucoco order standard. We conclude, however, that in rejecting Plaintiff's claim, the court mistakenly relied on a distinction between curative and palliative treatment not drawn under the no-fault law.
B.
The source of a dichotomous approach to curative/ palliative treatment for no-fault purposes appears to have been the Yucoco order. At trial, Allstate asserted the Yucoco order "held that allowing treatment that is merely for comfort and pain management is no longer legally valid in light of the 1993 amendments made to the Hawaii no- fault law."
In that order, the circuit court cited HRS § 431:10C-308.6, which established peer review of provider fees and treatment that exceeded specified schedules. That statute stated, in part, that " he fee schedules or treatment guidelines may be exceeded if a provider of treatment or rehabilitative services finds that the nature of the injuries and the process of recovery require a treatment plan resulting in fee schedules or treatment guidelines to be exceeded." (Emphasis added.)
Concluding that " he phrase `process of recovery require' plain and unambiguous[,]" the circuit court reasoned that "a person's entitlement to no-fault benefits in a situation where the proposed treatment exceeds the fee schedule and treatment frequency guidelines should be determined by whether or not the treatment contributes to the recovery process mandated by statute[.]" The circuit court thus held that " pplication of a comfort and pain management standard is inconsistent with the existing statutes[.]" As indicated supra, the Yucoco order was subsequently reversed by memo
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