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Samsel v. Allstate Insurance Company12/12/2002
Defendant/Appellant Allstate Insurance Co. appealed from an adverse summary judgment on a claim for breach of the medical payments coverage provisions of an automobile policy Allstate issued to Plaintiffs/Appellees Michael and Cynthia Samsel. The court of appeals affirmed, holding that reasonable medical expenses paid on behalf of Lisa Samsel, the injured party, by her health maintenance organization (HMO) were expenses actually incurred by Lisa for purposes of Allstate's medical payments coverage, notwithstanding the provisions of A.R.S. § 20-1072. Samsel v. Allstate Ins. Co., 199 Ariz. 480, 19 P.3d 621 (App. 2001). This petition for review followed. We have jurisdiction pursuant to Arizona Constitution article VI, § 5(3) and Rule 23, Ariz.R.Civ.App.P. We granted review to consider a question of first impression: are expenses for medical services necessary to treat injuries actually incurred by the insured within the meaning of the medical payment coverage of an automobile policy when those expenses are paid by the insured's HMO and a statute immunized the HMO's enrollees from legal liability for covered expenses.
FACTS
In August 1995, Lisa Samsel was injured in a Tucson automobile accident. She was taken by ambulance to University Medical Center (UMC) and treated there. The following day, Lisa signed a UMC "Conditions of Admission" form, agreeing in part to "pay all of Hospital charges as and when billed." At the time of the accident, Lisa was an insured under an Allstate automobile policy issued to her parents in 1993. The Allstate policy included medical payments coverage with a limit of $10,000, for which her parents paid an additional annual premium of $300. Lisa was also enrolled, since April 1995, in Partners Health Plan (Partners), an HMO regulated as a health care services organization pursuant to A.R.S. §§ 20-1051 et seq.
As a result of her injuries, Lisa's charges at UMC totaled $16,413 in medical services and $2,494 in physicians' services. Upon her discharge, UMC billed Lisa as a guarantor. Partners ultimately paid all but $313.55 of Lisa's expenses. She subsequently filed a claim with Allstate under the Samsels' medical payments coverage. Allstate paid only the $315.55 that had not been paid by Partners and denied coverage on the remaining charges, saying that because Partners was obligated to and did pay the charges, Lisa had not actually incurred those expenses, as required by the medical payments provision of its policy.
The Samsels sued Allstate, alleging among their claims breach of contract and bad faith. They subsequently amended their complaint to add class action allegations. Both parties moved for summary judgment on the breach of contract claim before proceeding on the class action issues. The trial judge granted summary judgment in favor of the Samsels on the breach of contract claim, denied Allstate's motion on the same issue, and entered final judgment in favor of the Samsels for $9,686.45, representing the difference between the coverage limits and the $313.55 Allstate previously paid.
On Allstate's appeal, the court of appeals held that when Lisa signed UMC's admission form, she agreed to accept financial responsibility and liability for her medical expenses. Samsel, 199 Ariz. at 485 16, 19 P.3d at 626 16. Therefore, Lisa actually incurred those expenses under the medical payments provision of Allstate's policy. Id. The court found that notwithstanding the provisions of subsections (A) to (C) of A.R.S. § 20-1072, subsection (E) of that statute allowed Lisa to accept financial responsibility for her hospital and medical expenses even though most of the expenses were paid by Partners. Id. at 484 12
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