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Gamata v. Allstate Insurance Co.4/28/1999
randum opinion of the supreme court.
HRS § 431:10C-308.6 was in effect at the time of this case but was not directly involved since Allstate did not initiate peer review of the charges involved. However, we believe that the circuit court construed the phrase "process of recovery" too narrowly and the court thus erred in relying on the Yucoco order. In our view, it is evident that a recovery process broadly implicates all necessary treatment, including management of pain and suffering and the use of diagnostic procedures such as the MRI. HRS § 431:10C-308.6 was repealed effective January 1, 1998. 1997 Haw. Sess. L. Act 251, § 59, at 551. We see no basis in the existing no-fault statutes before or after the repeal of HRS § 431:10C-308.6 for distinguishing curative from palliative treatment for the purpose of describing no-fault benefits.
In this case, the governing statute was HRS § 431:10C- 103(10)(A)(i) and (ii), which defined " o-fault benefits" as " ll appropriate and reasonable expenses necessarily incurred for medical, hospital, surgical, professional, nursing, dental, optometric, ambulance, prosthetic services, products and accommodations furnished, . . . x-ray, . . . psychiatric, physical, and occupational therapy and rehabilitation[.]" (Emphasis added.) The supreme court has held that "the law provides . . . a no-fault claimant is entitled to `appropriate and reasonable expenses necessarily incurred[.]'" Richard v. Metcalf, 82 Hawaii 249, 255, 921 P.2d 169, 175 (1996) (quoting HRS § 431:10C-103(10)(A) (Supp. 1989)). The statutory standard to have been applied by the court, then, was whether the expenses were "appropriate and reasonable" and "necessarily incurred." We do not discern any language in HRS chapter 431:10C indicating the legislature intended no- fault benefits to be restricted on the basis of whether the services provided were "curative" or "palliative." Indeed, services expressly covered under the no-fault benefits umbrella, such as ambulance and x- ray services, would not directly result in "curing" a patient. In light of the plain language in HRS § 431:10C-103(10)(A), a curative/palliative distinction is only generative of confusion.
In ruling, the court noted that Dr. Portner said "he not know whether [Plaintiff's improvement was] due to treatment or the passage of time[.]" We believe that the court's singular emphasis on this statement was misplaced. As explained above, the standard to be applied was whether the expenses were appropriate, reasonable, and necessarily incurred. Dr. Portner had testified to that effect.
V.
Finding that the court erred, we vacate its oral order and the judgment. We remand the case on the grounds set forth below, but first discuss the court's rejection of post-denial evidence.
Obviously, on remand, evidence regarding the purpose and reasons for Dr. Portner's recommended MRI and nerve root injection treatment would be relevant to whether Plaintiff's claim was properly denied. We conclude, further, that the court must consider the post- denial evidence in this case.
In applying the recovery standard, the court subscribed to Allstate's position that the post-denial condition and treatment of Plaintiff was irrelevant. In its trial memorandum, Allstate took the position that its October 13, 1997 denial of "any benefits" was a denial of "future no-fault benefits," and therefore its November 12, 1997 letter denying Dr. Portner's two treatment plans was "arguable unnecessary." In rejecting the two treatment plans, the November 12 letter had referred to Plaintiff's "current complaints." (Emphasis added.) However, to the extent that the November 12 letter was considered by the cour
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