HRS § 431-10C-304 - Obligation to pay personal injury protection benefits

For purposes of this section, the term "personal injury protection insurer" includes personal injury protection self-insurers. Every personal injury protection insurer shall provide personal injury protection benefits for accidental harm as follows: (1) Except as otherwise provided in section 431:10C-305(d), in the case of injury arising out of a motor vehicle accident, the insurer shall pay, without regard to fault, to the provider of services on behalf of the following persons who sustain accidental harm as a result of the operation, maintenance, or use of the vehicle, an amount equal to the personal injury protection benefits as defined in section 431:10C-103.5(a) payable for expenses to that person as a result of the injury: (A) Any person, including the owner, operator, occupant, or user of the insured motor vehicle; (B) Any pedestrian (including a bicyclist); or (C) Any user or operator of a moped as defined in section 249-1; provided that this paragraph shall not apply in the case of injury to or death of any operator or passenger of a motorcycle or motor scooter as defined in section 286-2 arising out of a motor vehicle accident, unless expressly provided for in the motor vehicle policy; (2) Payment of personal injury protection benefits shall be made as the benefits accrue, except that in the case of death, payment of benefits under section 431:10C-302(a)(5) may be made immediately in a lump sum payment, at the option of the beneficiary; (3) (A) Payment of personal injury protection benefits shall be made within thirty days after the insurer has received reasonable proof of the fact and amount of benefits accrued, and demand for payment thereof. All providers must produce descriptions of the service provided in conformity with applicable fee schedule codes; (B) If the insurer elects to deny a claim for benefits in whole or in part, the insurer shall, within thirty days, notify the claimant in writing of the denial and the reasons for the denial. The denial notice shall be prepared and mailed by the insurer in triplicate copies and be in a format approved by the commissioner. In the case of benefits for services specified in section 431:10C-103.5(a) the insurer shall also mail a copy of the denial to the provider; and (C) If the insurer cannot pay or deny the claim for benefits because additional information or loss documentation is needed, the insurer shall, within the thirty days, forward to the claimant an itemized list of all the required documents. In the case of benefits for services specified in section 431:10C-103.5(a) the insurer shall also forward the list to the service provider; (4) Amounts of benefits which are unpaid thirty days after the insurer has received reasonable proof of the fact and the amount of benefits accrued, and demand for payment thereof, after the expiration of the thirty days, shall bear interest at the rate of one and one-half per cent per month; (5) No part of personal injury protection benefits paid shall be applied in any manner as attorney's fees in the case of injury or death for which the benefits are paid. The insurer shall pay, subject to section 431:10C-211, in addition to the personal injury protection benefits due, all attorney's fees and costs of settlement or suit necessary to effect the payment of any or all personal injury protection benefits found due under the contract. Any contract in violation of this provision shall be illegal and unenforceable. It shall constitute an unlawful and unethical act for any attorney to solicit, enter into, or knowingly accept benefits under any contract; (6) Disputes between the provider and the insurer over the amount of a charge or the correct fee or procedure code to be used under the workers' compensation supplemental medical fee schedule shall be governed by section 431:10C-308.5; and (7) Any insurer who violates this section shall be subject to section 431:10C-117(b) and (c). [L 1987, c 347, pt of §2; am L 1992, c 124, §11; am L 1993, c 6, §20 and c 205, §27; am L 1997, c 251, §41; am L 1998, c 275, §21; am L 2000, c 138, §1] Case Notes Where plaintiff alleged that defendant insurance company refused to pay claims for personal injury protection benefits, (1) defendant's motion to dismiss certain counts of the first amended complaint denied in part and granted in part; among other things, counts one to four of plaintiff's "first claim" stated a claim for relief that was authorized under this section; and (2) plaintiff's cross motion for summary judgment and adjudication or preliminary injunction denied. 685 F. Supp. 2d 1123 (2010). Disputed issue of material fact existed as to whether or not the information requested by defendant insurer from plaintiff personal injury protection company was necessary and reasonable; defendant insurer was entitled to do some investigation to determine whether claimed benefits are appropriate and reasonable. 732 F. Supp. 2d 1107 (2010). Section entitles motorcycle passenger to claim no-fault benefits against automobile driver's policy for passenger's injuries received in accident between driver's vehicle and motorcycle. 81 H. 302, 916 P.2d 1203. Term "any person" in paragraph (1)(A)(i) includes motorcycle passengers. 81 H. 302, 916 P.2d 1203. In light of the unambiguous mandatory language of paragraph (3)(B), an insurer is required to provide written notice of its denial--in whole or in part--of the claim for benefits; written notice to the claimant is required where the denial or partial denial relates to the treatment service and/or the charges therefor; where the denial or partial denial involves treatment services, the insurer must also provide written notice to the provider. 109 H. 185, 124 P.3d 930 (2005). Where insurer's denial of plaintiff's claim for no-fault benefits was based upon an open question of law--whether "the reasons" as used in paragraph (3)(B) means "all reasons"--there was no bad faith on the part of insurer for not having stated all the reasons for its denial of plaintiff's claim. 109 H. 537, 128 P.3d 850 (2006). Hawaii's no-fault legislative scheme did not establish doctor's status as a third party beneficiary as a matter of law. 116 H. 159, 172 P.3d 471 (2007). Paragraph (1)(B) (1987) created a statutory right to survivors' loss benefits. 88 H. 345 (App.), 966 P.2d 1071. Pursuant to paragraph (1)(B) (1987) and §431:10C-103(10)(B) (1987), upon the death of an insured, the insurer is obligated to provide the insured's survivor a survivor's loss benefit of up to either (1) $15,000 where the insured has purchased only the basic no-fault coverage, or (2) the expanded limits of no-fault benefits where the insured has contracted for it under an optional additional coverage. 88 H. 345 (App.), 966 P.2d 1071. The plain language of paragraph (1) requires a causal connection between a motor vehicle accident and any injury for which a claim for no-fault insurance benefits is made. 101 H. 21 (App.), 61 P.3d 532. Insurer violated the time requirements of paragraph (3)(C) (1993) when it delayed granting or denying insured's claim for no-fault benefits pending (1) receipt of answers from insured's treating physicians to insurer's questions regarding the underlying cause of the medical condition that required insured to undergo bypass surgery a few days after a motor vehicle accident, and (2) insured's undergoing two independent medical examinations; however, the commissioner wrongly concluded that insurer's violation of these time requirements procedurally barred insurer from contesting the substantive merits of insured's claim. 101 H. 311 (App.), 67 P.3d 810. Under paragraph (5), an award of attorney's fees and costs is mandatory if a claimant prevails in a settlement or suit for no-fault benefits; and under §431:10C-211(a), an award of attorney's fees and costs may, in the exercise of a court's or the commissioner's discretion, be awarded to a nonprevailing claimant, as long as the claim is not determined to be unreasonable, fraudulent, excessive, or frivolous. 104 H. 375 (App.), 90 P.3d 267. Paragraph (3)(B) (1993) applies to billing disputes and this section's notice requirement is triggered by a partial denial of claims in the form of reduced or partial payments by an insurer; thus, trial court erred in finding that insurer was not required to issue a formal notice of denial of benefits pursuant to paragraph (3)(B) (1993) after it made both reduced and partial payments on physician's claims. 117 H. 477 (App.), 184 P.3d 792 (2008). Paragraph (4) (1993) is applicable when a payment due is delayed in conjunction with a billing dispute; thus, physician was entitled to interest on the balance withheld by insurer thirty days after physician submitted physician's billing statements and demand for payment; insurer was not permitted to withhold payment for an indeterminate period of time, without interest, while it sought additional information from physician. 117 H. 477 (App.), 184 P.3d 792 (2008). The doctrine of equitable tolling cannot be applied to expand the two-year statute of limitations period in §431:10C-315 (1993) based solely on an issuer's failure to provide a formal notice of denial required pursuant to paragraph (3) (1993) in conjunction with a reduced or partial payment. 117 H. 502 (App.), 184 P.3d 817 (2008).