Maritele Burgos and another v. Pilgrim Insurance Company, March 15, 2010
2010 Mass. App. Div. 49
Insurance, “Personal Injury Protection” Benefits, Motion for Summary Judgment
The plaintiffs, an automobile driver (Burgos) and her friend, were insured by Pilgrim, the defendant insurance company. The plaintiffs commenced this action after Pilgrim denied their claims. Summary judgment was entered for Pilgrim. Plaintiffs appealed. The dispositive issue was whether the plaintiffs' delayed submissions of their PIP applications prejudiced the defendant-insurer's investigation, thereby justifying denial of their PIP claims. The Appellate Division affirmed the summary judgment for Pilgrim, the defendant-insurer.
Facts
On April 19, 2006, Pilgrim received two incomplete personal injury protection (PIP) applications from the two plaintiffs. The applications alleged an automobile accident almost 3 months earlier, and constituted the first notice received by Pilgrim of the accident. The two PIP applications failed to state whether they had received treatment for alleged injuries, failed to state medical expenses to date, and lacked any attached medical bills or treatment records.
On August 30, 2006, 7 months after the alleged accident, Pilgrim received partial medical bills and records from the plaintiffs. These records showed that both plaintiffs had begun treatments before the submission of the PIP applications. The treatments had ended more than 2 months earlier in June 2006. Pilgrim was effectively precluded from ordering contemporaneous independent medical examinations (“IME”) of the plaintiffs to assess the necessity of their four months of treatments.
Pilgrim scheduled an examination under oath (“EUO”) for each plaintiff. The plaintiffs failed to appear for the examinations. Pilgrim issued notice of denial of claims on April 2, 2007. The plaintiffs commenced this action on April 9, 2007. A motion judge ruled that there was no genuine issue of material fact in the case, and that Pilgrim was entitled to judgment as a matter of law based on its defense that it was prejudiced in its ability to investigate the plaintiffs' claims due to their delayed notice of the identity of their medical providers and the nature and costs of their medical treats.
Review of Summary Judgment for Pilgrim
The Appellate Division reviewed the allowance of Pilgrim's summary judgment motion de novo.
The plaintiffs' April 2006 PIP applications were incomplete and failed to include “reasonable proof of the fact and amount of expenses incurred.” G.L.c. 90, §34M. The applications failed to reference treatment the plaintiffs had already begun and failed to identify the providers or medical services received. Existing medical reports and hospital and treatment bills were not attached. The plaintiffs' April 2006 filings thus failed to constitute effective PIP claims under §34M. The lack of information provided in the PIP claims limited the investigative options open to Pilgrim. Pilgrim was denied the opportunity for a medical review of treatment records or contemporaneous IMEs of the plaintiffs.
The prejudice asserted by Pilgrim was that it was deprived of an opportunity to obtain IMEs of the plaintiffs prior to the completion of their chiropractic treatments. The PIP statute entitles insurers to IMEs and IME results are a component of the customary “reasonable proof” of PIP “amounts due by an insurer for necessary and reasonable medical treatment.” The plaintiffs argued that Pilgrim was not prejudiced because it could have scheduled IMEs after its receipt of their medical bills and records in August. The Appellate Division noted that one of the purposes of IMEs is to establish the need for continued treatment. The plaintiffs' treatment had already stopped before the August receipt of records.
The plaintiffs' PIP application delay prejudiced Pilgrim by depriving it of evidence critical to its investigation and payment of, and defense against, the plaintiffs' G.L.c. 90, §34M claim. That prejudice justified Pilgrim's denial of PIP benefits.
Summary judgment for Pilgrim, the defendant, was affirmed.
- Prepared by AYK
