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Llanes v. Daso9/19/2000
fees, $259.25 in costs, and $16.75 in sheriff's fees.
is entitled to Judgment against [Llanes]. Wilson v. AIG Hawaii Ins. Co., [supra]. Gamata v. Allstate Insurance Co.., 90 Hawaii 213, 978 P.2d 179 (App. 1999). is awarded reasonable attorney's fees and costs for its defense of the claim filed by [Llanes]. shall file an affidavit of fees and costs.
Llanes filed a motion for reconsideration on June 10, 1999, which the district court denied. The present appeal followed.
II. DISCUSSION
Llanes argues that the district court erred in ruling against him based on this court's opinion in Wilson. In that case, the provider submitted a treatment plan to the insurer, requesting approval for a surgical procedure. The provider performed the surgery, but the insurer challenged it as inappropriate and unreasonable and denied payment of no-fault benefits. The insured filed suit in district court, the insurer moved for summary judgment, and the court granted the motion. On appeal, this court affirmed, holding that, under District Court Rules of Civil Procedure (DCRCP) Rule 17(a), the insured was not a "real party in interest" with respect to the claim for no-fault benefits. We explained that HRS § 431:10C-304(1)(B) (1993) required the insurer to pay directly to the provider any medical expenses incurred and that HRS § 431:10C-308.5(e) (1993) precludes the provider from billing or otherwise attempting to collect payment from the insured. See Wilson, 89 Hawaii at 49-50, 968 P.2d at 651-52. Thus, insofar as the "no-fault laws completely insulate an insured from the billing/payment process," the insured is not a real party in interest to a "claim against [the insurer] for no-fault benefits to satisfy [his or] her provider's unpaid bill." Id. at 50, 968 P.2d at 652.
Llanes maintains that he has legal rights as a party to his no-fault contract and as an "insured" under the no-fault statute, see HRS § 431:10C-303(a) (1993), and thus qualifies as a real party in interest as contemplated by DCRCP Rule 17(a). His arguments simply resuscitate the same issues already considered by this court in Wilson. As we explained therein, while insureds certainly have a general right to benefits under contract and statute to benefits, once medical services are rendered, insureds are insulated by statute from any payment obligation, and any dispute as to the payment of no-fault benefits to pay for the services rendered lies solely between the insurers and providers. This reasoning is rooted in the express terms of the statutory scheme, and none of Llanes's arguments persuade us to the contrary. We thus affirm the district court to the extent that it ruled that, under Wilson, Llanes was not a real party in interest with respect to claims for no-fault benefits for services rendered by Dr. Daso.
In this case, however, even beyond the treatment specified in the treatment plans submitted by Dr. Daso, AIG issued a denial of "further chiropractic treatment after 10/11/97." AIG based its denial on the PRO report, which concluded that Llanes "has received the maximum benefit therapeutic benefit from the chiropractic care provided" and, thus, recommended that "continued chiropractic care is no longer reasonable or appropriate." At trial, AIG's representative confirmed that AIG had in fact "denied future chiropractic care."
The record therefore indicates that AIG denied not only the specific treatment plans submitted, but also any further treatment of chiropractic nature. In other words, AIG issued a blanket prospective denial of continuing chiropractic services or treatment. See generally Government Employees Ins. Co. v. Dang, 89 Hawaii 8, 967 P.2d 1066 (1998) (confirming
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